Adult Registration Form B

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First Last

Birth Date(Required)

EPWORTH SLEEPINESS SCALE (ESS)

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling 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.

Scale - Key

Use this 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 circle a number (0 to 3) for EACH situation:

Sitting and Reading(Required)

0

1

2

3

Watching Television(Required)

0

1

2

3

Sitting inactive in a public place (theatre/meeting)(Required)

0