Epworth Sleepiness Scale

* First Name:
MI:
* Last Name:
Your age (years)
* Gender:

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.

Use the following scale to choose the most appropriate number for each situation:

0 = would never fall asleep

1 = slight chance of falling asleep

2 = moderate chance of falling asleep

3 = high chance of falling asleep

It is important that you answer each question as best you can.

THANK YOU FOR YOUR COOPERATION