Epworth Sleepiness Scale HiddenToday's Date MM slash DD slash YYYY Name* First Last Date of Birth* MM slash DD slash YYYY 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. The following scale reflects the values we assign to each level of dozing likelihood.0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozingSitting and readingPlease select…would never dozeslight chance of dozingmoderate chance of dozinghigh chance of dozingWatching televisionPlease select…would never dozeslight chance of dozingmoderate chance of dozinghigh chance of dozingSitting, inactive, in a public place (e.g. a theatre or a meeting)Please select…would never dozeslight chance of dozingmoderate chance of dozinghigh chance of dozingAs a passenger in a car for an hour without a breakPlease select…would never dozeslight chance of dozingmoderate chance of dozinghigh chance of dozingLying down to rest in the afternoon when circumstances permitPlease select…would never dozeslight chance of dozingmoderate chance of dozinghigh chance of dozingSitting and talking with someonePlease select…would never dozeslight chance of dozingmoderate chance of dozinghigh chance of dozingSitting quietly after a lunch without alcoholPlease select…would never dozeslight chance of dozingmoderate chance of dozinghigh chance of dozingIn a car, while stopped for a few minutes in trafficPlease select…would never dozeslight chance of dozingmoderate chance of dozinghigh chance of dozingTOTAL
