Epworth Sleepiness Scale

Patient's Full Name

Today's Date

Legal Guardian's Full Name (if patient is a minor)

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Date of Birth

Epworth Sleepiness Scale

This questionnaire was developed to determine the level of daytime sleepiness in individuals. It has become one of the most frequently used methods for determining a person’s average level of daytime sleepiness.

Please rate how likely you are to doze or fall asleep in the following situations by selecting the response that best applies. If you have not done some of these activities recently, select what would most likely happen if you were in that situation.

Use the following scale to choose the most appropriate number for each situation:

0 = would NEVER doze
1 = SLIGHT CHANCE of dozing
2 = MODERATE CHANCE of dozing
3 = HIGH CHANCE of dozing

It is important that you answer each question as best you can.

Sitting and reading

Watching TV

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

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

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

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

Epworth Sleepiness Score

Please add together the total number from your responses above and enter total here.

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Epworth Sleepiness Scale

Epworth Sleepiness Scale

Center for TMJ & Sleep Solutions NW