Please fill out next two pages if you want to be evaluated for any sleep related complaints.
Please consult your spouse/bed partner when answering the following questions. Answer questions as it best
describes a typical night or sleep pattern.
On a typical night:
Please circle your choice regarding the indicated problem by using following guideline
1 = Never; 2 = Almost Never; 3 = Sometimes; 4 = Almost Always; 5 = Always
THE EPWORTH SLEEPINESS SCALE: How likely are you to doze off or fall asleep in the following situations? This refers to your usual way of life in recent times. Use the following scale to choose the appropriate number.
0 =Would never dose off 1 = Slight chance of dozing
2 = Moderate chance of dozing 3 = High chance of dozing
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