Sleepiness Test

In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? Even if you have not done some of these things recently, try to work out how they would have affected you.  Use the following scale to choose the most appropriate number in each situation.

EPWORTH SLEEPINESS SCALE

Feel free to print this and fill it out before coming into our office. It might also be a good idea to give a copy to that spouse who snores!

Your Name: ____________________________________________
Date of Birth: ____/____/_____

0 = WOULD NEVER DOZE
1 = SLIGHT CHANCE OF DOZING
2 = MODERATE CHANCE OF DOZING
3 = HIGH CHANCE OF DOZING 

SITUATION

CHANCE OF DOZING

Sitting and Reading

__________

Watching TV

__________

Sitting inactive in public places (i.e., in a theatre)

__________

As a car passenger for an hour without a break

__________

Lying down to rest in the afternoon

__________

Sitting and talking to someone

__________

Sitting quielty after lunch (without alcohol)

__________

In a car, while stopping for a few minutes traffic

__________

Total Score=

__________


Have you had a Sleep Study? Yes No
Do you own a CPAP? Yes No
If so, do you use it nightly? Yes No

Signature: _________________________

Date: ___/____/___