Sleep Questionnaire

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?  This refers to your usual way of life in recent times.  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 dozing

 Situation                                                                                                      Chance of Dozing

 Sitting and Reading                                                                                          _____

 Watching TV                                                                                                          _____

 Sitting, inactive in a public place (e.g. theater, or meeting)             _____

 As a passenger in a car for an hour without a break                            _____

 Lying down to rest in the afternoon when circumstances permit   _____

 Sitting, talking with someone                                                                          _____

 Sitting quietly after a lunch without alcohol                                             _____

 In a car, while stopped a few minutes in traffic                                         _____