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TMJ Screening Survey
Stephanie Kethcart, DDS
Meet the Team
Epworth Sleepiness Scale
How old are you? (years):*
Over the last month, how likely have you been to fall asleep while doing things that are described bellow (activities)?
Even if you haven't done some of these things in the last month, try to imagine how they would have affected you.
Use the following scale to chose one number that best describes what has been happening to you during each activity over the last month. Check a box bellow.
Chance of falling asleep:
0 = would never fall asleep
1 = slight chance of falling asleep
2 = moderate chance of falling asleep
3 = high chance of falling asleep
It is important that you answer each question as best you can
Sitting and reading
Sitting and watching TV or a video
Sitting in classroom at school during the morning
Sitting and riding in a car or bus for about half an hour
Lying down to rest or nap in the afternoon
Sitting and talking to someone
Sitting quietly by yourself after lunch
Sitting and eating a meal
Please enter the text you see:
727 E. Bethany Home
Road, Suite #A100
Phoenix, AZ 85014-2156
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Central Phoenix Center for TMJ, Pain & Sleep Disorders
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