Epworth Sleepiness Scale Questionnaire Full Name:*Date:* Date Format: MM slash DD slash YYYY Date of Birth:* Date Format: MM slash DD slash YYYY Sex*MaleFemaleEmail:* Phone #:*A) 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. B) Even if you haven’t done some of these things recently try to work out how they would have affected you. C) Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing It is important that you answer each question as best you can.Sitting and Reading*0 - Would Never Doze1 - Slight Chance of Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingWatching TV*0 - Would Never Doze0 - Would Never Doze2 - Moderate Chance of Dozing3 - High Chance of DozingSitting, inactive in a public place (e.g. a theatre or a meeting)*0 - Would Never Doze1 - Slight Chance of Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingAs a passenger in a car for an hour without a break*0 - Would Never Doze1 - Slight Chance of Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingLying down to rest in the afternoon when circumstances permit*0 - Would Never Doze1 - Slight Chance of Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingSitting quietly after a lunch without alcohol*0 - Would Never Doze1 - Slight Chance of Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingSitting and talking to someone*0 - Would Never Doze1 - Slight Chance of Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingIn a car, while stopped for a few minutes in the traffic*0 - Would Never Doze1 - Slight Chance of Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingTotal