Pulmonary and Medicine Associates

Pulmonary and Medicine Associates, PLLC

27472 Schoenherr, Suite 100

Warren MI 48088

Phone: 586-751-8844

EPWORTH SLEEPINESS SCALE

Name *

Age *

Sex *

Male

Female

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 = Would never doze
1 = Slight chance of dozing

2 = Moderate chance of dozing
3 = High chance of dozing

Check the most appropriate choice below

1. While sitting and reading *

0 - never

1 - Slight chance

2 - Moderate chance

3 - High chance

2. While watching TV. *

0 - never

1 - Slight chance

2 - Moderate chance

3 - High chance

3. Sitting, inactive in a public place. (e.g., a movie theatre or a meeting) *

0 - never

1 - Slight chance

2 - Moderate chance

3 - High chance

4. As a passenger in a car for an hour without a break. *

0 - never

1 - Slight chance

2 - Moderate chance

3 - High chance

5. Lying down to rest in the afternoon when circumstances permit. *

0 - never

1 - Slight chance

2 - Moderate chance

3 - High chance

6. While sitting and talking to someone. *

0 - never

1 - Slight chance

2 - Moderate chance

3 - High chance

7. While sitting quietly after lunch without alcohol. *

0 - never

1 - Slight chance

2 - Moderate chance

3 - High chance

8. In a car, while stopped for a few minutes in the traffic. *

0 - never

1 - Slight chance

2 - Moderate chance

3 - High chance

EPWORTH SCORE:

STOP-BANG SLEEP APNEA QUESTIONNAIRE

STOP

Do you SNORE loudly (Louder than talking, loud enough to be heard through closed doors, or loud enough for your bed partner to wake you during the night)? *

Yes

Do you often feel TIRED, fatigued, or sleepy during the daytime (such as falling asleep during driving or talking to someone)? *

Yes

Has anyone OBSERVED you stop breathing, choking or gasping during your sleep? *

Yes

Do you have or are you being treated for high blood PRESSURE? *

Yes

BANG

BMI more than 35kg/m2 *

Yes

AGE over 50 years old? *

Yes

NECK circumference > 16 inches (40 cm)? *

Yes

Gender: Male? *

Yes

Total score: Yes 0 / No 0

Result: