Post-Therapy Epworth Sleepiness Scale

Patient Name

Title

First name

Middle name

Surname

Maiden name (if applicable)

Date of Birth (DD/MM/YYYY)

Post-Therapy Questions

Select the type of therapy you have been using

Please specify the type of therapy you have been using

How long have you been using the specified therapy?

In the following situations, please choose how likely you are to fall asleep or doze, by selecting the most applicable option:

	Never Doze/Not Applicable	Slight Chance of Dozing	Moderate Chance of dozing	High Chance of Dozing
1. Sitting and Reading
2. Watching TV
3. Sitting quietly in a public place (e.g. meeting or theatre)
4. As a passenger in a car for an hour without a break
5. Lying down to rest in the afternoon, when circumstances permit
6. Sitting and talking to someone
7. Sitting quietly after lunch without alcohol
8. In a car, while stopped for a few minutes in traffic