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....
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.
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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