EPWORTH SLEEPINESS SCALE Patient’s Name: First Last Date MM slash DD slash YYYY Score: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 the last three weeks. Even if you have not done some of these recently, try to work out how they would have affected you. Rate you chance of dozing in each situation.SITUATION Chance of dozingSitting and Reading 0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing Watching T.V. 0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing Sitting inactive in public place (theater, meeting, etc.) 0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing As a passenger in a car for a hour w/o a break 0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing Lying down to rest in the afternoon 0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing Sitting and talking to someone 0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing Sitting quietly after lunch without alcohol 0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing In a car, while stopped for a few minutes in the traffic 0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing
