We require that you complete the following survey prior to your initial appointment. Please fill out and submit the electronic survey below or download a printable PDF here.

The Epworth Sleepiness Scale

How likely are you to doze off in the following situations, in contrast to just feeling tired? Even if you have not done some of these things recently, try to work out how they would affect you.

Using the following scale, choose the most appropriate number for each of the situations:

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

Sitting and reading

Watching TV

Sitting in a public place inactive (e.g. a theatre or a meeting)

As a passenger in a car for an hour without a break

Laying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

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

Name

First Name

Last Name

Phone Number