Epworth Sleepiness Scale

Please be aware that you should only complete this form if you have been requested to do so by the practice.

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 have not done some of these things recently, try to work out how they would have affected you.

Use this scale to assess your sleepiness.

Epworth Sleepiness Scale

Epworth Sleepiness Scale

Please select your chance of dozing in the following situations

Sitting and Reading: *
Watching TV: *
Sitting, inactive in a public place (e.g. a theatre 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: *