Instructions:
Answer each question as accurately as you can. At
the end of the questionnaire, fill in your name, email address, phone and
other requested data (all optional). This information is only used to communicate
results back to you. All names, phone numbers, etc. are purged after their
intended use and are not made available to any other organization, commercial
entity or individual.
Do you snore?
Do you feel fatigued?
If your answer is "Yes" to one or both of
these questions, complete this sleep evaluation.
THE EPWORTH SLEEPINESS SCALE
How likely are you to doze off or fall asleep in
the following situations, in contrast to feeling just tired? This
refers to your usual way of life in recent times. Even if you have
not done some of these things recently try to work out how they would
have affected you. Use the following scale to choose the most appropriate
number for each situation.
0= Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing
Sitting and reading
0
1
2
3
Watching TV
0
1
2
3
Sitting inactive in a public place (e.g. a theater
or a meeting)
0
1
2
3
As a passenger in a car for an hour without a break
0
1
2
3
Lying down to rest in the afternoon when circumstances
permit
0
1
2
3
Sitting and talking to someone
0
1
2
3
Sitting quietly after a lunch without alcohol
0
1
2
3
In a car, while stopped for a few minutes in the
traffic
0
1
2
3
SLEEP EVALUATION
1) Do you sometimes experience a creeping feeling
in your legs?
Yes
No
2) Do you or have you ever been told that you kick
your legs at night?
Yes
No
3) Do you snore?
Yes
No
I don't know
If "yes" please continue with #4
If "no" or "I dont know" please continue with #8
4) Your snoring is...
softer than talking
as loud as talking
louder than talking
5) Your snoring occurs...
every/almost every night
a few times each week
once a week or less
6) Your snoring is also...
frequently interrupted by pauses/choking
occasionally interrupted by pauses/choking
not interrupted as far as you know
7) Do you snore in every body position?
Yes
No
I don't know
8) Do you have, or ever had a bed partner?
Yes
No
If "yes" please continue with #9
If "no" please continue with #12
9) Has your bed partner ever said that you have
pauses in your breathing or periods of stopped breathing during your
sleep?
Yes
No
10) Has your bed partner ever commented that you
snore?
Yes, loud snoring
Yes, soft snoring
No
11) If you snore, is it loud enough to bother her/him?
Yes
No
12) Has anyone besides a bed partner ever commented
on your snoring (roommate, neighbor, family, etc.)?
Yes, loud snoring
Yes, soft snoring
No
13) Do you feel fatigued or exhausted or tired
or not up to par?
nearly every day
3 to 4 times a week
once or twice a week
once or twice a month
never or hardly ever
14) Do you feel that in some way your sleep is
not refreshing or restful?
nearly every day
3 to 4 times a week
once or twice a week
once or twice a month
never or hardly ever
15) Do you have periods of the day when you have
trouble paying attention, remembering things or staying awake?
nearly every day
3 to 4 times a week
once or twice a week
once or twice a month
never or hardly ever
16) Do you have high blood pressure?
Yes
No
If "yes" are you being treated for high blood
pressure?
Yes
No
17) Do you wake up during the night or in the morning
with headaches?
Yes
No
18) Are you a shift worker?
Yes
No
19) Do you have trouble initiating and/or maintaining
sleep?
nearly every day
3 to 4 times a week
once or twice a week
once or twice a month
never or hardly ever
20) What do you feel is your ideal amount of sleep
per day?
2-4
5
6
7
8
9
10
21) Estimate the average number of hours of sleep
you had per day during the last week.
2-4
5
6
7
8
9
10
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