Epworth Sleepiness Evaluation - Home Sleep Delivered

Instructions

This questionnaire is a first step in determining whether you may have Sleep Apnea.
Enter a number in each box according to the scale below.
If you don't participate in some of these activities, use your best guess.

0Never

1Slight Chance

2Moderate Chance

3High Chance

Sitting & reading

Watching TV

Sitting, inactive in a public place

As a passenger in a car for an hour without break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after lunch without alcohol

In a car stopped for a few minutes in traffic (while you are the driver)

Total

* If you scored 10 or higher, the background of the total cell should be blue and is indicative of risk for Sleep Apnea.

* Even if your score is less than 10, we recommend completing this form, many cases scoring under 10 result in undiagnosed sleep apnea.

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Your Email*

Your First Name*

Last Name*

Your Primary Phone*

Gender

Date of Birth

Physician Name

Physician Phone

Physician Email

Comments

This field is for validation purposes and should be left unchanged.