Epworth Sleepiness Scale Survey
Rate the following situations according to how likely you are to doze off while doing each. Please base your response on how you feel at this moment using the following scale to rate each situation.
*
Rows
0
Would
NEVER
Doze
1
SLIGHT
Chance
of Dozing
2
MODERATE
Chance
of Dozing
3
HIGH
Chance
of Dozing
Sitting and reading
Watching TV
Sitting inactive in a public place
Sitting as a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch
Sitting in a car while stopped in traffic
Click "Next" to see your score.
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What's your Epworth Sleepiness Score?
Your score is:
Congratulations! your score is within the normal range for healthy adults.
Your score is above the normal range for healthy adults. We recommend you follow up with your primary care provider to discuss your sleepiness and possible treatment options.
Would you like St. Claire HealthCare to assist you in scheduling an appointment to follow up on your sleepiness?
Yes
No
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Who is your primary care provider?
Submit
Should be Empty: