Epworth Sleepiness Scale Printable Version Epworth Sleepiness Scale Patient Name * Date of Birth * Who is your GP? * Mobile number to contact you * Pleases complete this form if you have been asked to by your GP. How likely are you to doze off or fall asleep in the following situations? You should rate your chances of dozing off, not just feeling tired. Even if you have not done some of these things recently try to determine how they would have affected you. Sitting and reading * No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Watching TV * No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting inactive in a public place (eg theatre or meeting) * No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing As a passenger in a car for an hour without a break * No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Lying down to rest in the afternoon * No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting and talking to someone * No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting quietly after a lunch without alcohol * No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing In a car, whilst stopped for a few minutes in traffic * No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Epworth Score * Score Interpretation 0-7 : It is unlikely that you are abnormally sleepy. 8-9 : You have an average amount of daytime sleepiness. 10-15 : You may be excessively sleepy depending on the situation. 16-24 : You are excessively sleepy. This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data. Consent * I agree to the privacy policy reCAPTCHA If you are human, leave this field blank. Submit