2. Epworth Sleepiness Scale How likely are you to doze off or fall asleep in these situations, in your recent usual way of life?
Sitting and reading
0 — Would never doze 1 — Slight chance of dozing 2 — Moderate chance of dozing 3 — High chance of dozing
Watching TV
0 — Would never doze 1 — Slight chance of dozing 2 — Moderate chance of dozing 3 — High chance of dozing
Sitting inactive in a public place (e.g. a theatre or a meeting)
0 — Would never doze 1 — Slight chance of dozing 2 — Moderate chance of dozing 3 — High chance of dozing
As a passenger in a car for an hour without a break
0 — Would never doze 1 — Slight chance of dozing 2 — Moderate chance of dozing 3 — High chance of dozing
Lying down to rest in the afternoon when circumstances permit
0 — Would never doze 1 — Slight chance of dozing 2 — Moderate chance of dozing 3 — High chance of dozing
Sitting and talking to someone
0 — Would never doze 1 — Slight chance of dozing 2 — Moderate chance of dozing 3 — High chance of dozing
Sitting quietly after a lunch without alcohol
0 — Would never doze 1 — Slight chance of dozing 2 — Moderate chance of dozing 3 — High chance of dozing
In a car, while stopped for a few minutes in traffic
0 — Would never doze 1 — Slight chance of dozing 2 — Moderate chance of dozing 3 — High chance of dozing
3. STOP-Bang Snoring — do you snore loudly (louder than talking, or heard through closed doors)?
Yes No
Tired — do you often feel tired, fatigued or sleepy during the daytime?
Yes No
Observed — has anyone seen you stop breathing or choke/gasp during sleep?
Yes No
Pressure — do you have, or are you being treated for, high blood pressure?
Yes No
BMI — is your body mass index more than 35?
Yes No
Age — are you over 50 years old?
Yes No
Neck — is your neck circumference greater than 40 cm (16 inches)?
Yes No
Gender — are you male?
Yes No
Your answers are stored securely and only seen by our clinical team.
