Sleep History Questionnaire

Please correct the errors described below.

Sleep History

Epworth Sleepiness Scale

0=would NEVER doze 1=Slight chance of dozing 2=moderate chance of dozing 3=high chance of dozing

Please rate the chance of you dozing off in the following situations

Social History

Thank you for taking the time to complete the forms. We appreciate your help getting us this information.

Your information will be encrypted.