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Sleep Evaluation

Name:*

Date Of Birth:*

Email:*

Phone Number:*

Preferred contact method:

Epworth Sleepiness Scale:

How likely are you to doze off or fall asleep in the following situations? Select the number that best describes your likelihood of dozing off or falling asleep during the following situations. Even if you have not been in these situations recently, try to imagine how you would behave.

0 = No chance of dozing

2 = Moderate chance of dozing

1 = Slight 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

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 lunch (without alcohol)

0 1 2 3

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

0 1 2 3

Medications: List all prescribed or over-the-counter medication you are currently taking:

Medical History: List any significant injuries, illnesses, medical procedures, or treatments you have had: