EPWORTH SLEEPINESS SCALE

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EPWORTH SLEEPINESS SCALE Name: Sponsors last 4 of SSN#: DOB: Today s Date: Age (years): Gender (circle): MALE FEMALE How likely are you to doze off or fall asleep in the following situation, 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 Situation Chance of Dozing (0-3) Sitting and reading 0---1----2----3 Watching television 0---1----2----3 Sitting inactive in a public place, for example, a theater or meeting 0---1----2----3 As a passenger in a car for an hour without a break 0---1----2----3 Lying down to rest in the afternoon when cicumstances permit 0---1----2----3 Sitting and talking to someone 0---1----2----3 Sitting quietly after lunch without 0---1----2----3 alcohol Driving a car, while stopped for a few minutes in traffic 0---1----2----3

Name: Sponsor s last 4 of SSN# BRIEF SLEEP HISTORY Boise Sleep Laboratory Naval Medical Center Portsmouth What is your primary problem with your sleep? Have others observed you sleeping? Y / N If yes, what, if anything, have they told you about your sleep behavior? Do you snore? N / Y. If yes, how badly? Circle one. 1. Can be heard in the bedroom 2. Can be heard outside the bedroom with the door closed 3. Can be heard outside the bedroom with the door closed 4. Can be heard on another floor of the home 5. You or your bed partner frequently needs to leave the bedroom Do you have or are you being treated for any of the following medical conditions? (Check those that apply) a. High Blood Pressure (Hypertension) b. Diabetes (Abnormal blood sugar) c. Stroke d. Mini-stroke (TIA, transient ischemic attack) e. Heart Attack (myocardial infraction) f. Obstructive sleep apnea g. Narcolepsy 1

Have you had any of the following surgeries? (Check those that apply) h. Repair of nasal septum (septoplasty) i. Sinus surgery (Functional Endoscopic Sinus Surgery, turbinate reduction, etc.) j. Tonsillectomy k. Uvulopalatopharyngoplasty (UPPP) Do you take any prescription medicines? (Please list them below) l. m. n. o. p. q. r. s. t. Please check off below any of the listed problems you have on a regular basis, answer as best you can, there is no need to respond no : a. Weight gain in past year (lbs) sweating in sleep fatigue _ b. Watery eyes Floppy lid syndrome c. Stuffy nose Postnasal drip d. Chronic allergies Dry mouth in the morning e. Sore throat in the morning f. Chest pains palpitation g. Sleeping on more than one pillow because short of breath h. Cough Gasping at night Stopping breathing at night i. Snoring Heart burn/acid reflux Stomach ulcers u. Stomach bloating Urinating more than once at night v. Losing urine in bed Frequent urination 2

w. Varicose veins leg/ankle swelling x. Goiter Thyroid disease y. Feeling hot when those around you are comfortable z. Feeling cold when those around you are comfortable aa. Increased thirst bb. Easy bruising Anemia or low iron cc. Drug allergies frequent infections dd. Use of anti-inflammatory steroids (Prednisone) ee. Strange sensations in legs at night ff. Sudden loss of muscle strength when laughing or upset gg. Dreams when you are awake (other than daydreams) hh. Waking from sleep with body totally paralyzed ii. Seizures/Fits Sleep walking jj. Depression Insomnia Anxiety/panic attacks kk. Headaches most mornings Do any of your blood relatives have any of these medical problems? High Blood Pressure (hypertension) Sleep Apnea Narcolepsy Restless Leg Syndrome Heart Attack before age 50 Do you drink any of the following beverages regularly (every day)? a. Coffee YES / NO How many cups a day? b. Caffeinated soda pop YES / NO How many a day? c. Tea (hot,iced) YES / NO How many a day? Do you work shifts or stand watches at night frequently? During the work week, what times do you usually go to bed? During your days off, what times do you usually go to bed? During the weekends what times do you usually get out of bed? 3

Over the past 12 weeks, how often have you been bothered by any of the following problems? (Circle) Not at all Several Days More than half the days Nearly every day Little interest or pleasure in doing things 0 1 2 3 Feeling down, depressed, or hopeless 0 1 2 3 Trouble falling or staying asleep, or sleeping 0 1 2 3 too much Feeling tired or having little energy 0 1 2 3 Poor appetite or overeating 0 1 2 3 Feeling bad about yourself or that you are 0 1 2 3 a failure or have let yourself or your family down Trouble concentrating on things, such as 0 1 2 3 reading the newspaper or watching television Moving or speaking so slowly that other 0 1 2 3 people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead, or of hurting yourself 0 1 2 3 4 Privacy Advisory: We will not obtain personally identifying information about you when you visit our site unless you choose to provide such information to us. If you choose to send email to the site webmaster or submit an online feedback form, any contact information that you provide will be solely used to respond to your request and not stored.

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