At the bottom of this page is a link to open a printable version of the scale.
Name:
Today's Date:
Your Age (in years):
Sex (M or F):
Using the scale of numbers provided below (0 to 3), rate how likely you are to become extremely sleepy and doze during each circumstances described in the examples. Answer the questions using what has happened to you recently (during the last 6 months, for example). Even if you have not done the things in the examples recently, think about each of them and try to conclude how each would effect you.
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
| The Activity |
Your Score |
| Sitting and reading |
|
|
Watching TV
|
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| Sitting inactive in a public place (e.g. a theater or a meeting) |
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| As a passenger in a car for an hour without a break |
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| Lying down to rest in the afternoon when circumstances permit |
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| Sitting and talking to someone |
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| Sitting quietly after a lunch without alcohol |
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| In a car, while stopped for a few minutes in traffic |
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You also may open a printable copy the Epworth Sleepiness Assessment and bring it with you to your appointment. To open it you must have Adobe Acrobat Reader on your computer.
Click here to open the Epworth Sleepiness Assessment.
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