SoFHA
Patient Forms

Epworth Sleepiness Scale Paperwork

Description:

The SoFHA Epworth Sleepiness Scale papweork.

Code:

9.107

Issued:

04/09/2020

Revision:

Revised:

N/A

Patient Information

Name First, MI, Last

Date of Birth

Epworth Sleepiness Scale

Please estimate your risk of falling asleep in the following situations.

Sitting and Reading

None

Slight

Moderate

High

Watching TV

None

Slight

Moderate

High

Sitting inactive in a public place (Theater or Meeting)

None

Slight

Moderate

High

As a passenger in a car for an hour without a break

None

Slight

Moderate

High

Lying down to rest in the afternoon

None

Slight

Moderate

High

Sitting and talking to someone

None

Slight

Moderate

High

Sitting quietly after a lunch without alcohol

None

Slight

Moderate

High

In a car, while stopped for a few minutes in traffic

None

Slight

Moderate

High

Signature

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Patient Signature