Atomic Shrink, Incorporated

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Epworth Sleepiness Scale | Dr. Patricia Masuda-Story
Confidential patient questionnaire

Epworth Sleepiness Scale

Daytime Sleepiness Screening

Rate your likelihood of dozing or falling asleep in each routine daytime situation. The form will calculate your score and prepare the completed responses for Dr. Story.

Patricia Masuda-Story, Psy.D., QME drstory@atomicshrink.com
Questionnaire progress0 of 8 answered

Patient Information

Complete the identifying information below before beginning the questionnaire.

Instructions

How likely are you to doze off or fall asleep in each situation? Select one response for every situation. Base your answer on your usual way of life in recent times.
0Would never doze
1Slight chance of dozing
2Moderate chance of dozing
3High chance of dozing
Total Score 0 / 24
After selecting “SEND COMPLETED FORM,” your email application will open with the score and responses addressed to Dr. Story. Select Send in the email application to complete delivery.