Epworth Sleepness Scale

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Client Information

Appointment Information

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations ?

0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing

Social History

Review Of Systems

Do you now have or have you had any of the following since your last visit? (check all that apply)

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