Epworth Sleepiness Scale Form

Epworth Sleepiness Scale:

Most adults feel tired throughout the day. In many cases, it can be chalked up to a busy lifestyle, stress, and maybe even an over-reliance on caffeine. But what if it’s more than that? Is your sleepiness in a normal range… or could it point to something more troubling? Remember to always visit a licensed physician for diagnosis.

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

Sitting and reading

Watching television

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

FORM COMPLETED BY:

The above information is accurate to the best of my knowledge.

Form completed by:

Patient Signature or Parent or Guardian Signature (if patient is a minor):

Date: