Epworth Sleepiness Scale Name* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Today's Date* (Consider at the worse time of the day and in worse situation. This is required to get pre-authorization for your sleep study)In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation. 0 = WOULD NEVER DOSE 1 = SLIGHT CHANCE OF DOZING 2 = MODERATE CHANCE OF DOZING 3 = HIGH CHANCE OF DOZINGSitting and Reading* 0 1 2 3 Watching TV* 0 1 2 3 Sitting inactive in a public place (i.e., in a theatre)* 0 1 2 3 As a car passenger for an hour without a break* 0 1 2 3 Lying down to rest in the afternoon* 0 1 2 3 Sitting and talking to someone* 0 1 2 3 Sitting quietly after lunch (without alcohol)* 0 1 2 3 In a car, while stopping for a few minutes in traffic* 0 1 2 3 TotalCheck the box belowCommentsThis field is for validation purposes and should be left unchanged.
