Cardinal Sleep Disorder Centers of America
Daytime Sleepiness Test

Test based on the Epworth Sleepiness Scale

Employee name: _____________________________________________________
Company name: _____________________________________________________

Instructions: 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 estimate how they would have affected you using the scale below.

• 0 means that you would NEVER doze in this situation
• 1 means that there is a SLIGHT chance of dozing in this situation
• 2 means that there is a MODERATE chance of dozing in this situation
• 3 means that there is a HIGH chance of dozing in this situation

1. Sitting and reading      0 1 2 3
2. Watching television      0 1 2 3
3. Sitting inactive in a public place, for example, a theater or meeting      0 1 2 3
4. As a passenger in a car for an hour without a break      0 1 2 3
5. Lying down to rest in the afternoon      0 1 2 3
6. Sitting and talking to someone      0 1 2 3
7. Sitting quietly after lunch (without alcohol)      0 1 2 3
8. In a car while stopped in traffic      0 1 2 3

Fax this form to: 815-773-9099
or mail it to:
Cardinal Sleep Disorder Centers of America
3077 W. Jefferson St.,  Suite 210
Joliet, IL 60435

*please be sure to view our other convenient locations listed on our website

(888) 740-5700 • www.cardinalsleep.com •Fax: (815) 773-9099