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