EPWORTH SLEEP SCALE
Use
the following scale to choose the most appropriate number for each situation:
0 — no chance of nodding off
1 — slight chance of dozing
2 — moderate chance of sleeping
3 — high chance of falling asleep
Situations:
Chance of Dozing or Sleeping ____
Sitting and reading ____
Watching TV ____
Sitting inactive in a public place ____
Being a passenger in a motor vehicle for an hour or more ___
Lying down in the afternoon____
Sitting and talking to someone____
Sitting quietly after lunch (no alcohol)____
Stopped for a few minutes in traffic_____
while driving _____
TOTAL ________
PLEASE RETURN TO:
DR. ROBERT C. ALLEN MD, NEIGHBORHOOD FAMILY CARE
516 LINN STREET
ALLEGAN MI 49010
FAX: 866.708.5055
It is preferred if you could fax or email form once it is complete