EPWORTH SLEEPINESS SCALE RESULT

Date: [Date]
Patient: [Name or ID, age]
Form: [Adult ESS or ESS-CHAD, language, from the licensed source]
Completed: [By the patient alone, with help, or read aloud; interpreter if used]
Reason: [Daytime sleepiness, snoring, suspected sleep apnea, treatment review, or work assessment]

SCORE
Total: [0 to 24, all eight items answered]
Range: [Normal, mild, moderate, or severe excessive daytime sleepiness]
Previous ESS: [Dates and totals, or first score]

CONTEXT
Sleep hours: [Usual bedtime and wake time, and hours slept on work and free days]
Work pattern: [Day work, rotating shifts, nights, or long-haul driving]
Medicines and substances: [Sedating medicines, opioids, antihistamines, alcohol, cannabis, and caffeine]
Drowsy driving: [Dozing at the wheel, near misses, or crashes, and the license type]

RELATED FINDINGS
Breathing in sleep: [Snoring, witnessed apneas, choking or gasping, morning headaches]
Examination: [BMI, neck size, blood pressure, and airway]
Apnea risk: [STOP-Bang or other risk score, if used]
Other causes considered: [Low mood, thyroid, restless legs, cataplexy, insomnia, or body clock problems]
Impression: [Likely cause of the sleepiness, or still unclear]

PLAN
Next step: [Sleep study, sleep clinic referral, sleep hygiene, shift-work advice, medicine change, or treatment change]
Driving advice: [What was advised, and any licensing requirement discussed]
Teaching: [What the patient was told and understood]

REPEAT
Score again: [Date or interval, such as weeks after treatment starts]
What would change the plan: [The score or new symptom that prompts referral or a change]

Clinician: [Name, credentials]