ESS questionnaire - Ruysdael slaapkliniek

Do you have a patient number?*

Yes
No

Patient number*

Don't have a patient number yet? Please contact us:
Amsterdam
020 - 737 2302

The Hague
070 - 204 4114

Hidden

Intake flow?*

Yes
No

Hidden

STOP BANG score*

Hidden

ESS score*

Hidden

HADS A score*

Hidden

HADS D score*

Hidden

Length

Hidden

Weight

Hidden

BMI

Explanation

How easy do you doze off in different situations? It is not just about being tired, but about the feeling of being sleepy and refers to your current lifestyle. In case you haven't been in one of below's situation recently, try to imagine how you would feel.

Check for each situation how often or fast you would doze off.

During a conversation with someone else:*

Never
Sometimes
Pretty often
Always

During a visit to family or friends:*

Never
Sometimes
Pretty often
Always

During a passive relaxation (reading, watching tv):*

Never
Sometimes
Pretty often
Always

During an active relaxation:*

Never
Sometimes
Pretty often
Always

As a passenger during a car- or train ride of one hour: *

Never
Sometimes
Pretty often
Always

In the car when you need to wait 5 minutes (traffic light, traffic jam):*

Never
Sometimes
Pretty often
Always

In the afternoon or evening after eating:*

Never
Sometimes
Pretty often
Always

During working hours or daytime*

Never
Sometimes
Pretty often
Always

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