Preassessment Questionnaire

Epworth Sleepiness Questionnaire

If you think you may have a sleeping disorder, please take the following questionnaire. The scale is intended to help you evaluate the extent of your sleepiness.

Please use this as a tool to assist your physician in diagnosing and treating your symptoms. The following questionnaire is not intended to substitute for a medical assessment by your physician, but is intended to be taken with you when you visit your physician.

Use the following scale to assign the most appropriate number for each situation listed:
0 = Would Never Doze
1 = Slight Chance of Dozing
2 = Moderate Chance of Dozing
3 = High Chance of Dozing

Situation and Chance of Dozing

  1. Sitting and Reading  _______
  2. Watching Television _______
  3. Sitting, inactive in a public place (i.e. theater, meeting) _______
  4. As a passenger in a car for an hour without a break  _______
  5. Lying down to rest in the afternoon if circumstances permit _______
  6. Sitting and talking with someone _______
  7. Sitting quietly after lunch without alcohol _______
  8. In a car, while stopped for a few minutes in traffic _______

Sleepiness Score: 

  • Normal Range 0-6
  • Mild Sleepiness 7-10
  • Moderate Sleepiness 11-16
  • Severe Sleepiness 17+