Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your patient information. Fill in the fields for your medical record number (MR#), today's date, your name, marital status, gender, ethnicity, age, and date of birth (DOB).
3. Next, complete the height and weight sections by providing your height in feet and inches, and your weight in pounds.
4. In the 'Referred by' section, indicate the name of the person or medical professional who referred you to the Sleep Center.
5. Select the reason for your visit from the provided options, which include insomnia, sleep apnea, or other. If applicable, answer if you have previously been evaluated for a sleep disorder and if you have had an overnight sleep study.
6. Complete the Epworth Sleepiness Scale by rating your likelihood of dozing off in various situations. Use the scale provided and check the corresponding box for each scenario.
7. Proceed to answer the questions in the questionnaire section, which inquire about snoring, high blood pressure, sleepiness during the day, and other related sleep behaviors. Respond to each question honestly.
8. Next, fill out your sleep habits by providing information on your typical bedtime, time taken to fall asleep, wake time, and average sleep duration for weekdays and weekends.
9. Continue by responding to questions regarding any unusual sleep behaviors, such as grinding teeth or sleepwalking, and tick the boxes that apply.
10. If applicable, complete the CPAP section with how many nights per week you use it and any problems experienced while using it.
11. Fill out the social habits section, indicating your occupational status and answering questions regarding smoking, caffeine, and alcohol consumption.
12. Next, review family history, current medications, allergies, and major surgeries you have undergone, checking relevant boxes.
13. Complete the review of systems section by checking all boxes for any medical problems or symptoms you currently have or have had in the past.
14. Lastly, indicate your consent for potential research contact and provide your printed name, signature, diagnoses, and date.
15. Once all sections have been filled out, you can save changes, download a copy, print the completed form, or share it if necessary.

Take a moment to complete your document online today to ensure a smooth visit to the Weill Cornell Sleep Center.