Patient Name:

Epworth Sleepiness Scale

Please indicate how likely you are to doze off or fall asleep in the following situations:

(0=Never, 1=Slight, 2=Moderate, 3=High chance of dozing) Circle one response for each question

Sitting and reading
Watching Television
Sitting inactive in a public place (e.g. theater, meeting)
As a passenger in a car for one hour without a break
Sitting down quietly after lunch with no alcohol
Lying down to rest in the afternoon
Sitting and talking to someone
In a car, while stopped for a few minutes in traffic
Total:

Scoring: 0-7 = ok | 8-9 = Average Sleepiness | 10-15 Maybe Excessive Sleepiness | 16-24 = Excessively Sleepiness and Should Consider Medical Attention

Sleep Evaluation

Do you snore?
Would you, or your spouse, consider your snoring louder than a person talking?
Does your snoring occur almost every night?
Is your snoring bothersome to your bed partner?
Do you feel that in some way your sleep is not refreshing or restful?
Do you wake up at night or in the morning with headaches?
Do you experience fatigue during the day and have difficulty staying awake?
Do you have trouble remembering things or paying attention during the day?
Do you have high blood pressure?

Prior Diagnosis

Have you previously been diagnosed with sleep apnea?
If yes: When were you diagnosed(approx. mo/yr)
Were you put on CPAP Therapy for treatment?
Are you still using your CPAP every night?
Date: 
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