Epworth Sleepiness Scale
Please complete all sections as accurately as possible
First Name
*
Middle Name
Last Name
*
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Are you currently using a prescribed therapy for a sleeping disorder?
Yes
No
Please select the therapies you are currently using (select more than one if applicable)
CPAP/APAP Therapy
ASV Therapy
Bi-Level (NIV) Therapy
Nightshift Positional Therapy
Light Therapy
Mandibular advancement splint
Other
How long have you been using the above mentioned therapy?
Less than 4 weeks
1-6 months
6-12 months
1-2 years
2-5 years
5-10 years
Over 10 years
ESS Questionnaire:
In the following situations, please rate how likely you are to fall asleep
Sitting and Reading
*
Never Doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Watching TV
*
Never Doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting quietly after lunch without alcohol
*
Never Doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting and talking to someone
*
Never Doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting quietly in a public place
*
Never Doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Lying down to rest in the afternoon
*
Never Doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
As a passenger in a car for an hour without a break
*
Never Doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
In a car stopped in traffic
*
Never Doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
ESS Score
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