THE EPWORTH SLEEPINESS SCALE
Please print, fill out, and either fax, mail or bring this form with you to our office.

NAME:

DATE: AGE:

SEX: Male Female

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. 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 for each situation.

SITUATION

Sitting and reading

Watching TV

Sitting, inactive in a public place (e.g. a theater or a 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 the traffic