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Name: ________________________________ Today’s date: _________________


Your age (Yrs): _______________

Your sex (Male = M, Female = F): ________


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 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

It is important that you answer each question as best you can.

Chance of Dozing (0-3)

Sitting and reading _____
Watching TV _____
Sitting, inactive in a public place (e.g. a theatre or a meeting) _____

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 a lunch without alcohol _____

In a car, while stopped for a few minutes in the traffic _____




Copy write: M.W. Johns 1990-97

Epworth Scale: About Me
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