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: ___/____/___