The Epworth Sleepiness Scale

		Patient Surveys
		Disease Surveys
		Prescription Refills
		Diet Plans
		Sleep Surveys
		The Epworth Sleepiness Scale
		Sleep Disorder Self Test

		Surgery Preparation
		Precautions
		Pre-Operative Instructions
		Post-Operative Instructions
		Pollen Count

To take this survey, click here for the printable version.

Name: ___________________________________

Today's Date: _____________________________

Your age (years) _______________ Your sex (M/F) _______

How likely are you to doze off or fall asleep in the following situations in contrast to just feeling 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 scale below to choose the most appropriate number for each situation:

Situation*

Sitting and reading
Watching television
Sitting, inactive, in a public place (e.g., a theater, meeting)
Sitting 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
Sitting in a car while stopped for a few minutes in traffic

Chance of
Dozing
_____________
_____________
_____________
_____________

_____________
_____________
_____________
_____________

Scale for chance of dozing:
0 = never 1 = slight 2 = moderate 3 = high

*The numbers for the eight situations are added together to give a global score between 0 and 24.

http://www.entvi.com
Virgin Islands Ear, Nose & Throat
Paragon Medical Building, Suite 308
9149 Estate Thomas
St. Thomas, VI 00802

Phone: 340 - 774 - 8881 Fax: 340 - 774 - 1569

Email your questions or comments to: entvi@hotmail.com
© 2006 Virgin Islands Ear, Nose & Throat