Epworth Sleepiness Scale Click here to download a PDF of the Epworth Sleepiness Scale or fill out the online form below. Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth*How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life today. Even if you haven’t 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 dozingSituation:Sitting & Reading*0= would NEVER doze1= Slight chance of dozing2= Moderate chance of dozing3=High chance of dozingWatching TV*0= would NEVER doze1= Slight chance of dozing2= Moderate chance of dozing3=High chance of dozingSitting inactive in a public place (eg. Theatre or meeting)*0= would NEVER doze1= Slight chance of dozing2= Moderate chance of dozing3=High chance of dozingAs a passenger in a car for an hour without a break*0= would NEVER doze1= Slight chance of dozing2= Moderate chance of dozing3=High chance of dozingLying down to rest in the afternoon (when circumstances permit)*0= would NEVER doze1= Slight chance of dozing2= Moderate chance of dozing3=High chance of dozingSitting and talking with someone*0= would NEVER doze1= Slight chance of dozing2= Moderate chance of dozing3=High chance of dozingSitting quietly after lunch without alcohol*0= would NEVER doze1= Slight chance of dozing2= Moderate chance of dozing3=High chance of dozingIn a car, while stopped in traffic for a few minutes*0= would NEVER doze1= Slight chance of dozing2= Moderate chance of dozing3=High chance of dozingComment or QuestionsCAPTCHA
