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Epworth Sleepiness Scale (NM800111)

Epworth Sleepiness Scale (NM800111) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #


NM800111 (Rev. 02/09/17) Worksheet Only – Not a Medical EPWORTH SLEEPINESS SCALE
Record Document – DO NOT SCAN
Wisconsin Sleep
6001 Research Park Blvd., Madison, WI 53719
EPWORTH SLEEPINESS SCALE






Date: __________________________________

Your age (Yrs): ____________________ Your sex (Male – M, Female = F): __________

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?

This refers to your usual way of life recently.

Even if you haven’t done some of these things recently, try to figure out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation.

0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

It is importance that you answer each item as best as you can.

Situation Chance of Dozing (0-3)


Sitting and reading ____________________________________________

Watching TV _________________________________________________

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 ______

Total score of greater than or equal to 10 suggests possible clinically significant sleepiness

THANK YOU FOR YOUR COOPERATION













M.W. Johns 1990-1997

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