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1400 E 2nd Street, Defiance, OH 43512

(419) 784-1414

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Home » Patient Resources » Our Practice » Epworth Sleepiness Scale Survey

Epworth Sleepiness Scale Survey

Epworth Sleepiness Scale Survey

Instructions: Be as truthful as possible. Print the form. Read the situation select your response, then click "Submit."

Full Name*
Email Address*
Phone Number*
Sitting and Reading*
- Would Never Doze
- Slight Chance of Dozing
- Moderate Chance of Dozing
- High Chance of Dozing
Watching Television*
- Would Never Doze
- Slight Chance of Dozing
- Moderate Chance of Dozing
- High Chance of Dozing
Sitting inactive in a public place, for example, a theater or a meeting*
- Would Never Doze
- Slight Chance of Dozing
- Moderate Chance of Dozing
- High Chance of Dozing
As a passenger in a car for an hour without a break*
- Would Never Doze
- Slight Chance of Dozing
- Moderate Chance of Dozing
- High Chance of Dozing
Lying down to rest in the afternoon*
- Would Never Doze
- Slight Chance of Dozing
- Moderate Chance of Dozing
- High Chance of Dozing
Sitting and talking to someone*
- Would Never Doze
- Slight Chance of Dozing
- Moderate Chance of Dozing
- High Chance of Dozing
Sitting quietly after lunch when you've had no alcohol*
- Would Never Doze
- Slight Chance of Dozing
- Moderate Chance of Dozing
- High Chance of Dozing
In a car while stopped in traffic*
- Would Never Doze
- Slight Chance of Dozing
- Moderate Chance of Dozing
- High Chance of Dozing
Total Sum

Dr. Kaete Archer

1400 E 2nd Street, Defiance, OH 43512
(419) 784-1414

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