EPWORTH SLEEPINESS SCALE FORM

 

Instructions: Be as truthful as possible. Print the form. Read the situation in the first column; select your response from the second column; enter that number in the third column. Total all of the entries in the third column and enter the total in the last box.

Situation

Response

Score

Sitting and Reading

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

 

Watching Television

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

 

Sitting inactive in a public place, for

example, a theater or a meeting

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 an hour

without 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 when you’ve

had no 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 in traffic

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

 

 

A score of 10 or greater indicates a possible sleep disorder. Take the completed form to sleepLab when you make appointment with Dr. Rais

Call us: (804)897-3572 or (804) 897-3573

 You’re Name:                                                  Phone Number:

1340 Alverser Drive

Midlothian, VA 23113

 

T: (804) 897-3572 or (804) 897-3573

F: (804) 897-3574

E: reception@sleeplabca.com

 

You can also use our contact form.