|
Feel free to print this and fill it out before
coming in to our office. Might also be a good idea to give a copy to that
spouse who snores!
Patient
Name: Date of
Birth:
EPWORTH SLEEPINESS SCALE
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 or each situation.
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 a public place (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 quietly after lunch (without
alcohol) |
|
In a car, while stopping for a few minutes
in
traffic |
|
TOTAL SCORE = |
|
| |
|
| Have you had a sleep study? |
|
| Do you own a CPAP? |
|
If so, do you use it nightly? |
|
| |
|
| SIGNATURE: |
|
| DATE: |
|
| 
