www.bearleydental.net - Epworth Sleepiness Scale Form

EPWORTH SLEEPINESS SCALE
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date*

MonthDayYear
Date
This questionnaire was developed to determine the level of daytime sleepiness in individuals. It has become one of the most frequently used methods for determining a person's average level of daytime sleepiness.

Please rate how likely you are to doze or fall asleep in the following situations by selecting the response that best applies. If you have not done some of these activities recently, select what would most likely happen if you were in that situation.

0 - Would never doze
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing

	0	1	2	3
Sitting and reading
Watching television
Sitting inactive in a public place (e.g. A theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

Total Score

Interpreting Epworth Sleepiness Scale Scores

Normal	EDS	Higher levels of EDS
0-10	>10	>16

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Patient’s Name*

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Date*

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