The Epworth Sleepiness Scale Assessment

Please complete the following form, and one of our specialists will contact you:

Name

First Name

Last Name

Phone

(###)

###

####

Age

Weight

Gender

Male

Female

Have you ever had an evaluation at a sleep center?

Have you ever had an evalutation at a sleep center?

Yes

Do you have a CPCP device?

Yes

Have you attempted other therapies to deal with breathing and/or snoring issues?

Yes

If yes, provide details

How likely are you to doze off or fall asleep in the following situations?

Sitting and Reading

Watching TV

Sitting in a public place

(e.g.: theater, meeting or church)

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 traffic

Do you suspect that you or a loved one may have sleep apnea? Want to get the treatment you need? If so, then the first step you need to take is to complete our short assessment below. The Epworth Sleepiness Scale is currently used by doctors around the world to determine the likelihood that a person has sleep apnea.