Patient's Name *

Date *

Email *

Phone *

Use this scale to determine your patient’s level of sleepiness. Choose the most appropriate number for each situation:

0 = no chance of dozing

1 = slight chance of dozing or sleeping

2 = moderate chance of dozing or sleeping

3 = high chance of dozing or sleeping

Situation

Sitting and reading
Watching TV
Sitting inactive in a public place
As a passenger in a motor vehicle for an hour or more
Lying down to rest in the afternoon when circumstances permits
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
Total score (add up scores) (This is your Epworth score)

Please Tick The Ones That Apply To You:

1. Do you breathe through your mouth?

2. Do you frequently get a dry throat or non-productive cough?

3. Do you have any nasal allergies?

4. Do you snore or have you been told you snore while sleeping?

5. Do you stop or pause your breathing while sleeping?

6. Do you wake up fatigued?

7. Do you have morning tension or migraine headaches?

8. Do you easily get tired or fall asleep during the day?

9. Do you clench or grind your teeth during the night?

10. Do you clench or grind your teeth during the day?

11. Do you have any facial pain?

12. Do you usually drink alcohol or take sleep aids before going to bed?

13. Do you suffer from hypertension?

14. Have you been diagnosed with Chronic Fatigue Syndrome, Irritable Bowel Syndrome, Fibromyalgia or Temporomandibular Syndrome?