Epworth Sleepiness Scale

Name

First Last

Today's Date

Your Age*

Your Gender*

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 workout how they would have affected you. Use the following scale to choose the most appropriate number for each situation:

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Sitting and reading*

0
1
2
3

Watching TV*

0
1
2
3

Sitting, inactive in a public place (e.g. a theater or a meeting etc)*

0
1
2
3

As a passenger in a car for an hour without a break*

0
1
2
3

Lying down to rest in the afternoon when circumstances permit*

0
1
2
3

Sitting and talking to someone*

0
1
2
3

Sitting quietly after a lunch without alcohol*

0
1
2
3

In a car, while stopped for a few minutes in traffic*

0
1
2
3

Digital Signature of Consent*

By checking this box, I am providing a digital signature of consent to all the information provided.

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