HOME
SERVICES
DOCTORS
INFORMATION
FAQ
Health Professionals
Patients
Publications
Webinars & Seminars
BLOG
FORMS & REFERRALS
Appointment Request Form
Lung Function Request Form
Sleep Study Request Form
Medical Review Referral Form
Patient Registration Form
Medical History
Epworth Sleepiness Scale
Stop-Bang Questionnaire
Asthma Control Questionnaire
Vocal Cord Dysfunction Questionnaire
CONTACT US
Menu
HOME
SERVICES
DOCTORS
INFORMATION
FAQ
Health Professionals
Patients
Publications
Webinars & Seminars
BLOG
FORMS & REFERRALS
Appointment Request Form
Lung Function Request Form
Sleep Study Request Form
Medical Review Referral Form
Patient Registration Form
Medical History
Epworth Sleepiness Scale
Stop-Bang Questionnaire
Asthma Control Questionnaire
Vocal Cord Dysfunction Questionnaire
CONTACT US
Appointment
Forms
Epworth Sleepiness Scale
FORMS
Fill all required fields (★) to submit the form.
Patient details:
Full Name:
(Required)
★ Title
Mr
Mrs
Ms
Miss
Other
Prefix
First
Last
Preferred name:
Date of birth:
(Required)
DD slash MM slash YYYY
Mobile Number
(Required)
Home Phone:
Address:
Email address
(Required)
Height:
Weight:
How likely are you to dose 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 have not done some of these things recently try to workout how they would have affected you. Use the following scale to choose the most appropriate number of each situation:
0: No chance of dozing
1: Slight chance of dozing
2: Moderate chance of dozing
3: High chance of dozing
1. Sitting and reading
(Required)
0
1
2
3
2. Watching TV
(Required)
0
1
2
3
3. Sitting inactive in a public place (e.g a theater of meeting)
(Required)
0
1
2
3
4. As a passenger in a car for an hour without a break
(Required)
0
1
2
3
5. Lying down to rest in the afternoon when circumstances permit
(Required)
0
1
2
3
6. Sitting and talking to someone
(Required)
0
1
2
3
7. sitting quietly after a lunch without alcohol
(Required)
0
1
2
3
8. In a car, while stopped for a few minutes in traffic
(Required)
0
1
2
3
Scoring:
Confirm:
(Required)
I acknowledge for the safety of others that I have provided true and accurate details and I agree that may details can be used for contact tracing.
(Required)
