Patient Name:(Required) Date:(Required) MM slash DD slash YYYY Take a moment to think about day-to-day life over the past few weeks. How likely are you to doze off or fall asleep verses just feeling tired while participating in a situation that requires your attention, such as driving, reading, or attending a meeting?The Epworth Sleepiness Scale presents various daily situations and asks you to rate your degree of sleepiness in each circumstance. Even if you have not done some of these things recently, try to think about how they would affect you. Use the following scale to choose the most appropriate number for each situation. 0 = No chance of dozing 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing SituationChance of DozingSitting 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 traffic SCORE:To check your sleepiness score, total the points. Check your total score to see how sleepy you are:1 – 9 Your score is average. 10+ Your score suggests that you may suffer from excessive sleepiness and should seek medical attention and discuss about having a sleep test./p> Δ
