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.
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Situation |
Response |
Score |
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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 |
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|
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 |
|
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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 |
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|
In a car driving while stopped in traffic |
0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing |
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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:
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