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1 6700 W. Ninth Ave. Amarillo, TX Phone (806) THE EPWORTH SLEEPINESS SCALE Full name: Male Female Date: Age: How likely are you to doze off or fall asleep in the following situations, in contrast to feeling tired? This refers to your usual way of life in recent times. Even if you have not 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 2 = MODERATE chance of dozing 1 = SLIGHT chance of dozing 3 = HIGH chance of dozing CHANCE OF DOZING Sitting and reading Watching TV Sitting, inactive in a public place (e.g. movie theatre or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in the traffic
2 SLEEP QUESTIONNAIRE 6700 W. Ninth Ave. Amarillo, TX (806) Use the following scale to choose the most appropriate number for each situation: Do you feel that you get too little sleep at night? Do you feel that you get too much sleep at night? Have you ever had a poor night s with getting to sleep at night? because of waking up at night? with non-restorative sleep (no matter how much sleep you get, you do not wake up rested)? with tiredness (not sleepiness) during the day? with sleepiness during the day? On a weekday, what time do you usually go to bed? AM PM 10 On a weekday, what time do you usually get up? AM PM 11 On a weekday, what time do you usually take a nap? AM PM 12 On a weekend or day off, what time do you go to bed? AM PM 13 On a weekend or day off, what time do you get up? AM PM 14 On a weekend or day off, what time do you take a nap? AM PM 15 Do you watch TV or read in bed before going to sleep? YES NO 16 Do you use sleeping aids or medication? YES NO 17 How long after going to bed does it take you to decide to go to sleep? HRS MIN 18 How long does it take you to fall asleep, after you decide to? HRS MIN 19 What is the total number of hours of sleep that you usually get? (Do not include time awake in bed) HRS MIN
3 20 How many times do you wake up during a typical night? TIMES 21 How long is a typical wake time? HRS MIN If you do awaken during your normal sleep time, which part(s) of your sleep time is it likely to First 1/3 Middle 1/3 Last 1/3 22 happened? 23 How many times do you get out of bed during a typical night? Times 24 How long is the typical longest time out of bed? HRS MIN have thoughts racing through your 25 mind? feel sad or depressed? have anxiety (worry about things)? feel muscular tension? feel afraid of not being able to go to 30 feel unable to move, or feel paralyzed? notice parts of your body startle or jerk? experience restless legs (crawling or aching feelings, unable to keep legs still)? experience vivid, dream-like scenes (hallucinations) even though you are still awake? experience any pain or discomfort? sleep with someone else in your room? sleep with someone else in your bed? sleep on a special bed/mattress? have disturbed, restless 39 disturb the sleep of your bed partner?
4 provide assistance to someone or something else (child, invalid, pet, etc)? have nasal congestion? snore? hold your breath, or stop breathing? suddenly wake up gasping for air or unable to breath? wake up with a choking sensation? have some other breathing problem? sweat excessively? sleepwalk? sleep talk? grind your teeth? have leg twitching or jerking while you are a have other unusual movement during get up to eat after going to sleep disturbed because of stomach or abdominal pains? sleep disturbed because of leg cramps? sleep disturbed because of paresthesia (pins and needles) in your arms and/or legs? sleep disturbed because of an itching sensation? sleep disturbed because of any other kind of pain or intense discomfort?
5 sleep disturbed because of being short of breath in a flat position? sleep disturbed because of gas in your stomach, or indigestion? sleep disturbed because of hunger? sleep disturbed because of thirst? sleep disturbed because of awakening with the urgent need to urinate? # times sleep disturbed because of intense heart pain (angina)? sleep disturbed because of any other chest pains? sleep disturbed because of asthma? sleep disturbed because of persistent coughing? During the day, how long does it take you to get going in the morning? HRS MIN During the day, how often do you feel extremely alert and energetic all day?
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