Sleep Questionnaire

Your health is important to us. Please complete the form below to give us the opportunity to assist you with any sleep related challenges you may have.

Your Contact Details

* Your Name

* Email Address

Telephone Number

Epworth Sleepiness Scale

For each situation below, give yourself a score of 0 to 3 where: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing

If you can’t relate to some of the questions below, please think of a similar scenario that will be more applicable to your own circumstances. How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?

1. Sitting and reading

2. Watching Television

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

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

5. Lying down to rest in the afternoon

6. Sitting and talking to someone

7. Sitting quietly after lunch (when you have not had alcohol)

8. In a car, while stopped in traffic