Self Screening Questionnaire

The Epworth “Sleepiness” test has been used for many years in both diagnosis and research of Sleep Disordered Breathing.

Sleepiness may:

  • indicate a SERIOUS UNDERLYING DISEASE
  • lead to heart attack, stroke, anxiety, depression, headaches, memory loss, sexual dysfunction, irritability
  • cause work/road ACCIDENTS

To take the Epworth “Sleepiness” Test, please fill out the form below.

Epworth Sleepiness Test

  • mm/dd/yyyy
  • How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just 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 = no chance of dozing | 1 = slight chance of dozing | 2 = moderate chance of dozing | 3 = high chance of dozing
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