Sunil N. Lalla, M.D. PA, Bharti Lalla, M.D. FAAP

SUNIL LALLA, MD FCCP

Epworth sleepiness scale

First Name * Last Name * Date of Birth * Date of Completion *

The following questionnaire will help you measure your general level of daytime sleepiness. You are to rate the chance that you would doze off or fall asleep during different routine daytime situations. Answers to the questions are rated on a reliable scale called the Epworth Sleepiness Scale (ESS). Each item is rated from 0 to 3, with 0 meaning you would never doze or fall asleep in a given situation, and 3 meaning that there is a very high chance that you would doze or fall asleep in that situation. How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Even if you haven't done some of these activities recently, think about how they would have affected you.

Sitting and reading * Watching TV * Sitting inactive in a public place * Being a passenger in a motor vehicle for an hour or more * Lying down in the afternoon * Sitting and talking to someone * Sitting quietly after lunch (no alcohol) * Stopped for a few minutes in traffic while driving * TOTAL * Signature: * Date of Completion: *