Epworth Sleepiness Scale - Evaluation
Please answer all questions below and electronically sign
Full Name (First Last) *
Your answer
*
Would Never Doze (0)
Slight Chance of Dozing (1)
Moderate Chance of Dozing (2)
High Chance of Dozing (3)
While sitting and reading....
Watching television....
Sitting, inactive in a public place
As a pasenger in a car for about an hour without a break
Lying down to rest in the afternoon....
Sitting and talking with someone....
Sitting quietly after lunch without alcohol
In a car, while stopped at a light....
TERMS OF ACCEPTANCE and SIGNATURE
I, the responder noted above, for this Epworth Sleepiness Evaluation, warrant the truthfulness of the information provided in this document. by Checking the box below and electronically signing my name I agree that this information is true, correct and complete. I also grant Dr. Sherry Tsai DDS Inc to share this information with other providers and insurance companies as needed.
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Required
Electronic Signature (Please Type full Name) *
Your answer
This Legal Medical Form may be executed by original, facsimile, and electronic signatures, each of which when affixed shall be deemed to be an original and a legal form of documentation.
Total Score (for office use only)
Your answer
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