Epworth Scale

Date

Name

First NameLast Name

How likely are you to DOSE 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. Even if you have not done some of the things recently, try to work out how they would have affected you. Please check on box per line. If you have currently on CPAP, please answer how you presently feel.

Chance of dozing off. (Please circle the boxes that best describes you)

	Never	Slight	Moderate	High
Sitting and Reading.
Watching TV.
Sitting, inactive in a public place (meeting or theater).
As a passenger in a car for an hour without a break.
Lying down to rest in the afternoon when permitted.
Sitting and talking to someone.
Sitting quietly after lunch without alcohol.
In a car, while stopped for a few minutes in traffic.

Briefly sleep symptoms checklist: (Please check box that best describes you)

	Never	Rarely	Frequently	Always
I snore loudly.
I awaken gasping or choking for breath.
I have problems falling asleep or staying. (insomnia)
My sleep is restless.
My sleep is disturbed by unusual behaviors: Nightmares, sleepwalking, dream enactments, tongue biting, bedwetting, etc.
I fall asleep while driving.
I've been told that I stop breathing in my sleep.

What time do you go to bed?

What time do you go to bed on weekdays?

What time do you go to bed on weekends?

What time do you wake up on weekdays?

What time do you wake up on weekends?

What time do you wake up?

Do you awaken refreshed?

Do you nap?

How often do you nap? (times per day/week)

How long are your naps? (minutes)

Are you a shift worker?

If YES: what shift do you work?

Have you had a significant weight change since your last sleep study?

Have you been told that you kick your legs during sleep?