Epworth Sleepiness Scale

Patient's Name: ____________________________________________ Ht.________ Wt.________

DOB: ______________ Phone: _______________________ Neck________ BP________

Use this Tool to Measure Sleep Deprivation

The Epworth Sleepiness Scale (below) was developed by researchers in Australia and is widely used by sleep professionals around the world to measure sleep deprivation.

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. If you have not done some of these things recently, think about how they have affected you in the past.

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

0 = no chance of dozing

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., a theater or a meeting)

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

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after lunch without alcohol

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

Total

Do you snore? Yes/No Moderately/Severely

Have you had a sleep study = Yes/No

Do you have a CPAP = Yes/No

Daytime Sleepiness = Yes/No

Unrefreshed sleep = Yes/No

Observed Apnea's = Yes/No

Frequent awakenings = Yes/No

Bruxism = Yes/No

GERD = Yes/No

TMD = Yes/No

Date: _____________________