Epworth Sleepiness Scale

Patient Information

First name

Initial

Last name

Email address

Phone number

DOB

Weight

Height

Today's date

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

1: Sitting and Reading

2: Watching TV

3: Sitting, inactive in a public place (e.g. theater, meeting)

4: As a passenger in a car for an hour without a break

5: Lying down to rest in the afternoon when circumstances permit

6: Sitting and talking to someone

7: Sitting quietly after a lunch without alcohol

8: In a car, while stopped for a few minutes in traffic

9: Total Score

Medications: If you are not taking any medications please reply "N/A"

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