Skip to content
For Professionals
Our Solutions
Expand
Treatment Options
Oral Appliance Therapy
Snoring and Sleep Apnea
Expand
Snoring
Sleep Apnea
Sleep Assessment​
Forms & Resources
Expand
Patient Care
Pre-Treatment Sleep Questionnaire
New Patient Form
Insurance Package
Book Now
For Professionals
Toggle Menu
Epworth Sleepiness Scale
Step
1
of
2
- Personal Information
50%
Epworth Sleepiness Scale
Name
(Required)
First
Last
Gender
(Required)
Male
Female
Other
Date of Birth
(Required)
DD slash MM slash YYYY
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently try to work out how they would have affected you.
Situation chance of dozing?
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting and reading?
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Watching TV?
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting, inactive in a public place (e.g. a theatre or a meeting?
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
As a passenger in a car for an hour without a break
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Lying down to rest in the afternoon when circumstances permit
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting and talking to someone
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting quietly after a lunch without alcohol
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
In a car, while stopped for a few minutes in the traffic
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Want To Improve Your Sleep?
Book Your FREE Consultation
Book Now
Our Solutions
Toggle child menu
Expand
Treatment Options
Oral Appliance Therapy
Snoring and Sleep Apnea
Toggle child menu
Expand
Snoring
Sleep Apnea
Sleep Assessment​
Forms & Resources
Toggle child menu
Expand
Patient Care
Pre-Treatment Sleep Questionnaire
New Patient Form
Insurance Package