ESS questionnaire

Do you have a patiënt nummer?*

Yes
No

Patient number*

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

The Hague
070 - 204 4114

Intake flow?*

Ja
Nee

STOP BANG score*

ESS score*

HADS A score*

HADS D score*

Lengte

Gewicht

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:*

Nooit
Af en toe
Vrij vaak
Altijd

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

Nooit
Af en toe
Vrij vaak
Altijd

During an active relaxation:*

Nooit
Af en toe
Vrij vaak
Altijd

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

Nooit
Af en toe
Vrij vaak
Altijd

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

Nooit
Af en toe
Vrij vaak
Altijd

In the afternoon or after dinner:*

Nooit
Af en toe
Vrij vaak
Altijd

During working hours or daytime*

Nooit
Af en toe
Vrij vaak
Altijd

Check the box - this is to prevent spam.

What are you looking for?

Explanation

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