Epworth Sleepiness Scale
This is a form for recording the Epworth Sleepiness Scale. It is a standalone form ie. it doesn't require an image file to be uploaded with it. Contributed by Shelter Lee, Crossroads Family Practice, Chilliwack, BC.
EpworthSleepinessScale.html
—
HTML,
9Kb
File contents
<html>
<title>Epworth Sleepiness Scale</title>
<head>
<style type="text/css">
p.title{
text-transform: uppercase;
font-size: 16;
font-family: Arial;
font-weight: bolder;
text-align: left;
color: black;
}
p.heading{
font-weight: bolder;
}
td.heading1{
font-size: 12;
font-family: Arial;
font-weight: bold;
text-align: left;
vertical-align: top;
color: white;
background-color:black ;
border-width: 1;
}
td.heading2{
font-size: 12;
font-family: Arial;
font-weight: bold;
text-align: left;
vertical-align: top;
color: white;
background-color: #505050;
border-width: 1;
}
td.heading3{
font-size: 12;
font-family: Arial;
font-weight: bold;
text-align: center;
vertical-align: top;
color: black;
background-color: #E0E0E0 ;
border-width: 1;
}
tr.odd{
background-color: #ffffff;
}
tr.even{
background-color: #dddddd;
}
td.question{
font-size: 12;
font-family: Arial;
font-weight: normal;
text-align: left;
vertical-align: top;
color: black;
border-width: 1;
}
td.answer{
font-size: 12;
font-family: Arial;
font-weight: normal;
text-align: center;
vertical-align: top;
color: black;
border-width: 1;
}
td.normaltext{
width: 100%;
font-size: 12;
font-family: Arial;
font-weight: normal;
text-align: left;
vertical-align: top;
color: black;
background-color: white;
border-width: 0;
}
input.formtext{
width: 100%;
height: 100%;
font-size: 12;
font-family: Arial;
font-weight: normal;
text-align: left;
vertical-align: top;
color: black;
background-color: white;
border-width: 1;
border-style: solid;
}
textarea.formtext{
width: 100%;
height: auto;
font-size: 12;
font-family: Arial;
font-weight: normal;
text-align: left;
vertical-align: top;
color: black;
background-color: white;
border-width: 1;
border-style: solid;
}
</style>
<!-------Script to maximize window on loading----------->
<script language="JavaScript1.2">
<!--
top.window.moveTo(0,0);
if (document.all) {
top.window.resizeTo(screen.availWidth,screen.availHeight);
}
else if (document.layers||document.getElementById) {
if (top.window.outerHeight<screen.availHeight||top.window.outerWidth<screen.availWidth){
top.window.outerHeight = screen.availHeight;
top.window.outerWidth = screen.availWidth;
}
}
//-->
</script>
<!----------End maximizing window scipt---------->
<!-- CSS Script that removes textarea and textbox borders when printing ---(put this inbetween <header></header>)----------------->
<style type="text/css" media="print">
div.DoNotPrint {
display: none;
}
input.noborder {
border : 0px;
background: transparent;
}
textarea.noborder {
scrollbar-3dlight-color: transparent;
scrollbar-3dlight-color: transparent;
scrollbar-arrow-color: transparent;
scrollbar-base-color: transparent;
scrollbar-darkshadow-color: transparent;
scrollbar-face-color: transparent;
scrollbar-highlight-color: transparent;
scrollbar-shadow-color: transparent;
scrollbar-track-color: transparent;
background: transparent;
overflow: hidden;
//scrollbar : none;
border : 0px;
}
</style>
<!-- ----------------------------------------------------------------------------------------- -->
<script type="text/javascript" language="javascript">
function getCheckedValue(radioObj) {
if(!radioObj)
return parseInt(0);
var radioLength = radioObj.length;
if(radioLength == undefined)
if(radioObj.checked)
return parseInt(radioObj.value);
else
return parseInt(value);
for(var i = 0; i < radioLength; i++) {
if(radioObj[i].checked) {
return parseInt(radioObj[i].value);
}
}
return parseInt(0);
}
function totalScore(){
var i = 0;
i += getCheckedValue(document.FormName.Q1);
i += getCheckedValue(document.FormName.Q2);
i += getCheckedValue(document.FormName.Q3);
i += getCheckedValue(document.FormName.Q4);
i += getCheckedValue(document.FormName.Q5);
i += getCheckedValue(document.FormName.Q6);
i += getCheckedValue(document.FormName.Q7);
i += getCheckedValue(document.FormName.Q8);
//i += getCheckedValue(document.FormName.Q9);
// i += getCheckedValue(document.FormName.Q10);
document.FormName.EpworthScore.value = i;
if (i<=9){
document.getElementById("normal").style.background='yellow';
document.getElementById("borderline").style.background='white';
document.getElementById("abnormal").style.background='white';
}
else if (i>=10 && i<=11){
document.getElementById("normal").style.background='white';
document.getElementById("borderline").style.background='yellow';
document.getElementById("abnormal").style.background='white';
}
else{
document.getElementById("normal").style.background='white';
document.getElementById("borderline").style.background='white';
document.getElementById("abnormal").style.background='yellow';
}
}
</script>
</head>
<body>
<form method="post" action="" name="FormName">
<p class="title">
Epworth Sleepiness Scale
</p>
<div name="demographics">
<table width="100%">
<tr>
<td class="heading1" width=25%>Patient name</td>
<td class="formtext"><input class="formtext" name="PatientName" type="text" oscarDB=patient_name>
</tr>
<tr>
<td class="heading1">Date:</td>
<td class="formtext"><input class="formtext" name="TodaysDate" type="text" oscarDB=today>
</tr>
</table>
</div>
<br>
<div name="Questionnaire">
<table width="100%">
<tr>
<td class="heading2" width=40%>Situation:</td>
<td class="heading2" width=15%>would never doze (0)</td>
<td class="heading2" width=15%>slight chance of dozing (1)</td>
<td class="heading2" width=15%>moderate chance of dozing (2)</td>
<td class="heading2" width=15%>high chance of dozing (3) </td>
</tr>
<tr class="odd">
<td class="question"> 1. Sitting and reading</td>
<td class="answer"><input type="radio" name="Q1" value="0"></td>
<td class="answer"><input type="radio" name="Q1" value="1"></td>
<td class="answer"><input type="radio" name="Q1" value="2"></td>
<td class="answer"><input type="radio" name="Q1" value="3"></td>
</tr>
<tr class="even">
<td class="question">2. Watching TV</td>
<td class="answer"><input type="radio" name="Q2" value="0"></td>
<td class="answer"><input type="radio" name="Q2" value="1"></td>
<td class="answer"><input type="radio" name="Q2" value="2"></td>
<td class="answer"><input type="radio" name="Q2" value="3"></td>
</tr>
<tr class="odd">
<td class="question">3. Sitting, inactive in a public place (e.g., a theatre or a meeting)</td>
<td class="answer"><input type="radio" name="Q3" value="0"></td>
<td class="answer"><input type="radio" name="Q3" value="1"></td>
<td class="answer"><input type="radio" name="Q3" value="2"></td>
<td class="answer"><input type="radio" name="Q3" value="3"></td>
</tr>
<tr class="even">
<td class="question">4. As a passenger in a car for an hour without a break</td>
<td class="answer"><input type="radio" name="Q4" value="0"></td>
<td class="answer"><input type="radio" name="Q4" value="1"></td>
<td class="answer"><input type="radio" name="Q4" value="2"></td>
<td class="answer"><input type="radio" name="Q4" value="3"></td>
</tr>
<tr class="odd">
<td class="question">5. Lying down to rest in the afternoon when circumstances permit</td>
<td class="answer"><input type="radio" name="Q5" value="0"></td>
<td class="answer"><input type="radio" name="Q5" value="1"></td>
<td class="answer"><input type="radio" name="Q5" value="2"></td>
<td class="answer"><input type="radio" name="Q5" value="3"></td>
</tr>
<tr class="even">
<td class="question">6. Sitting and taking to someone</td>
<td class="answer"><input type="radio" name="Q6" value="0"></td>
<td class="answer"><input type="radio" name="Q6" value="1"></td>
<td class="answer"><input type="radio" name="Q6" value="2"></td>
<td class="answer"><input type="radio" name="Q6" value="3"></td>
</tr>
<tr class="odd">
<td class="question">7. Sitting quietly after a lunch without alcohol</td>
<td class="answer"><input type="radio" name="Q7" value="0"></td>
<td class="answer"><input type="radio" name="Q7" value="1"></td>
<td class="answer"><input type="radio" name="Q7" value="2"></td>
<td class="answer"><input type="radio" name="Q7" value="3"></td>
</tr>
<tr class="even">
<td class="question">8. In a car, while stopped for a few minutes in traffic</td>
<td class="answer"><input type="radio" name="Q8" value="0"></td>
<td class="answer"><input type="radio" name="Q8" value="1"></td>
<td class="answer"><input type="radio" name="Q8" value="2"></td>
<td class="answer"><input type="radio" name="Q8" value="3"></td>
</tr>
</table>
<br>
<table>
<tr>
<td><input type="button" onclick="totalScore()" value="Calculate Total Score"></td>
<td><input type="text" name="EpworthScore" size="10" value=""></td>
</tr>
</table>
</div>
<br>
<br>
<div name="Instructions" class="DoNotPrint">
<table>
<tr>
<td>
<p>Interpretation:</p>
</td>
</tr>
<tr>
<td>
<table>
<tr>
<td class="heading3">Score</td>
<td class="heading3"></td>
</tr>
<tr id="normal">
<td>0-9</td>
<td>Normal (a low score does not exclude significant daytime sleepiness)</td>
</tr>
<tr id="borderline">
<td>10-11</td>
<td>Borderline</td>
</tr>
<tr id="abnormal">
<td>12-24</td>
<td>Abnormal</td>
</tr>
</table>
</td>
</tr>
</table>
</div>
<br>
<br>
<!-- The submit/print/reset buttons ------------------------------------------------------------->
<div name="FunctionButtons" class="DoNotPrint">
<table>
<tr>
<td class="subjectline">
Subject: <input name="subject" size="40" type="text">
<input value="Submit" name="SubmitButton" type="submit">
<input value="Reset" name="ResetButton" type="reset">
<input value="Print" name="PrintButton" onclick="javascript:window.print()" type="button">
</td>
</tr>
</table>
</div>
</form>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->
</body>
</html>
