This form determines the need for you to have a user friendly sleep test, which will evaluate if you have a
sleep disorder. Sleep Disorders negatively affect your well being and especially your cardio-vascular health, but
can be effectively treated.
If your answer is NO to any of the above questions, please continue to Part 1.
If the answer is Yes to the above, PLEASE STOP.
Epworth Sleepiness Scale
How likely are you to doze off while doing the following activities? Please use the following scale:
0 = Never | 1 = Slight | 2 = Moderate | 3 = High
FOR OFFICE USE ONLY