Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Epworth Sleepiness Scale
Your information
Patient Name *
Date of Birth
____ / ____ / ________
Sitting and Reading
Watching Television
Sitting Inactive in a Public Place
As a Passenger in a Car for an Hour
Additional details
Lying Down to Rest in Afternoon
Sitting and Talking to Someone
Sitting Quietly After Lunch
In a Car While Stopped in Traffic
ESS Total Score
Sleepiness Severity Level
Epworth Sleepiness Scale template from formisoft.com. formisoft.com/intake-templates/epworth-sleepiness-scale