Patient Sleep Form 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 0 1 2 3 Watching Television 0 1 2 3 Sitting inactive in a public place (e.g. theater, meeting) 0 1 2 3 As a passenger in a car for one hour without a break 0 1 2 3 Sitting down quietly after lunch with no alcohol 0 1 2 3 Lying down to rest in the afternoon 0 1 2 3 Sitting and talking to someone 0 1 2 3 In a car, while stopped for a few minutes in traffic 0 1 2 3 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? yes no Would you, or your spouse, consider your snoring louder than a person talking? yes no Does your snoring occur almost every night? yes no Is your snoring bothersome to your bed partner? yes no Do you feel that in some way your sleep is not refreshing or restful? yes no Do you wake up at night or in the morning with headaches? yes no Do you experience fatigue during the day and have difficulty staying awake? yes no Do you have trouble remembering things or paying attention during the day? yes no Do you have high blood pressure? yes no Prior Diagnosis Have you previously been diagnosed with sleep apnea? yes no If yes: When were you diagnosed(approx. mo/yr) Were you put on CPAP Therapy for treatment? yes no Are you still using your CPAP every night? yes no Date: Submit Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.