Waterman Sleep, Inc Mount Dora, FL
Phone: 352-729-2843
Fax: 352-729-2846
Waterman Sleep, Inc Orange City, FL
Phone: 386-218-3591
Fax: 386-218-3594
THE EPWORTH SLEEPINESS SCALE
Name: ______________________________________ Date: ___________________
The Epworth Sleepiness Scale is widely used in the field of sleep medicine as a subjective
measure of a patient’s sleepiness. The test is a list of eight situations in which you rate your
tendency to become sleepy on a scale of 0, no chance of dozing, to 3, high chance of dozing.
When you finish the test, add up the values of your responses. Your total score is based on the
scale of 0 to 24. The scale estimates whether you are experiencing excessive sleepiness that
possibly requires medical attention.
How Sleepy Are You?
How likely are you to doze off or fall asleep in the following situations? You should rate your
chances of dozing off, not just feeling tired. Even if you have not done some of these things
recently, try to determine how they would have affected you. For each situation, decide whether
you would have:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Situations
In a car, while stopped for a few minutes in traffic
Chance of dozing
Sitting and reading
0
0
1
1
2
2
3
3
Watching TV
0
1
2
3
Sitting inactive in a public place (e.g. theater or a meeting)
0
1
2
3
As a passenger in a car for an hour without a break
0
1
2
3
Lying down to rest in the afternoon when circumstances permit
0
1
2
3
Sitting and talking to someone
0
1
2
3
Sitting quietly after a lunch without alcohol
0
1
2
3
Total score: __________
 A score of 10 or higher is an indication of excessive sleepiness and indicates that you
may benefit from further evaluation.
Waterman Sleep, Inc Mount Dora, FL
Phone: 352-729-2843
Fax: 352-729-2846
Waterman Sleep, Inc Orange City, FL
Phone: 386-218-3591
Fax: 386-218-3594
SLEEP STUDY ORDERS
Patient Name:
DOB:
/
/
Date:
Cell Phone:
Insurance Company:
Home Phone:
Insurance Phone:
ID# :
Group# :
Authorization #:
Phone:
Ordering Physician:
Fax:
Primary Physician:
Please attach recent clinical notes and additional demographics
PROCEDURES ORDERED:
A._____
Baseline Sleep Study, SPLIT Night Study, CPAP Titration to follow if indicated by the interpreting physician
Make all arrangements for my patient to be set up with CPAP/BiPAP equipment,
masks, humidifier, accessories, etc. as needed for their treatment of sleep apnea.
B._____
Baseline Sleep Study Only
C._____
Full Night CPAP/BiPAP Titration Only
D._____
MSLT (Multiple Sleep Latency Test)
E._____
MWT (Maintenance of Wakefulness Test)
F._____
Home Sleep Study
PLEASE CHECK APPROPRIATE DIAGNOSIS:
Sleep Apnea, unspecified
ICD-10 code G47.30
OSA (adult) (pediatric)
ICD-10 code G47.33
Sleep Disorder, unspecified
ICD-10 code G47.9
Hypersomnia, unspecified
ICD-10 code G47.10
Narcolepsy
ICD-10 code G47.41
Other Diagnosis:
______________________
Patient History/Comments: _________________________________________________________________________________________
Physician’s Signature ________________________________________Date____/____/______
Contact Person_______________________________________________________ (RN, MA, Referral Coordinator)