epworth Sleepiness Score - Abington Medical Centre

First Name *

Surname *

Date of Birth *

Address *

Address2 *

Town *

Postcode *

Telephone Number *

Email Address *

How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling tired? This refers to your usual way of life in recent times. 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 dozing

Please add your scores together and select from the range below

You will be contacted by the GP if you score 12 - 24

Disclaimer

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data

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Epworth Sleepiness Scale

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Epworth Sleepiness Scale

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