Registration Form Women s Health Initiative

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YWCA WHI 1500 14 th St. Lubbock, Texas 79401 Phone: (806) 687-8858 Fax: (806) 784-0698 1 Registration Form Women s Health Initiative Date: Name (Last, First, middle, Maiden) Age: Date of Birth SS # Mailing Address: Zip Code: County: City: Phone: Can we text you? Y N Are you employed? Y N If yes, can we call you at work? Y N Email Address: Place of Employment: Work Phone Ext Days and Hours Worked: Alternate Contact: Relationship Phone Client Information: Female Male Other (specify) Ethnicity: Hispanic or Latina Not Hispanic or Latina Race: Black White American Indian Asian Other(specify) Primary Language Spoken: English Spanish Other Were you born in the USA? Y N If no, where? How long have you lived in the USA? If no, are you a legal resident? Y N If yes, since when?(month, day, year) How would you describe the area you live in? City Rural Suburban Other Number of people living in household: Total monthly income (average): $ Sources of income: Job Retirement SSI Unemployment Other (specify) Do you have Medicare? Y N Medicaid? Y N Women s Health Medicaid? Y N Insurance? Y N Do you receive any financial medical assistance? (Specify) Residential home status: Own Rent Shelter Other (specify) What is the highest level of education completed or the last year of school you attended? GED High School Diploma College Degree No formal education Provider Preference If you are being referred for a mammogram, check the provider you prefer. UMC Breast Imaging Covenant s Joe Arrington Comprehensive Breast Center Covenant Mobile Unit

Cervical Screening History Date of last pap test: Results: Negative Abnormal Unknown If you have never had a pap test or not have had one done in the past 3 years, check why: Doctor has not recommended Did not know I should No transportation Too painful Didn t think anything would be found Nothing wrong with me Afraid of finding something Too young No family history of cancer Too expensive Too embarrassing Other Have you ever had an abnormal pap that required a follow up? Y N If yes, when? Circle any of the following if they apply or have ever applied to you. HPV HIV Cervical Dysplasia Immunocompromised Cervical Cancer Are you currently pregnant? Y N If yes, due date Are you post menopausal? Y N Breast Screening History Not including today, how long ago was you your last breast exam done by a nurse or a doctor? Never Less than 1 year ago 1-2 years ago 2 or more years Not Sure Have you ever been taught to examine your breasts? Y N How often do you examine your breast? More than once a month Monthly A few times a year Rarely Never Has a doctor ever told you that you have dense breast? Y N Did you know about mammograms before today? Y N How many times have you used the YWCA WHI to access breast health screening or cervical services? First Time Second Time Third Time More than 3 times (write number) What made you decide to use YWCA WHI for breast or cervical health services? (Check all that apply) Concerned about health Low cost/free Service Friendly Helpful Staff Culturally Sensitive Encouragement from family Healthcare Provider Advertisement Other Medical Health Screening Do you have any disabilities? Y N If yes, explain Do you have a history of smoking? Y N If yes, how long? How many per day? How do you identify yourself? Lesbian/Gay Bisexual Decline to State None of the above Other (specify) Check any of the following you have been diagnosed with: High Blood Pressure Diabetes Heart Disease or Angina Congestive heart Failure None Check all that apply where you have gone for medical services this past year: Emergency Room Family Planning Center Health Department Community Health Center Private Medical Provider Tribal Clinic Traditional Healer Hospital Clinic Other None 2

Patient Name MRN# Age Date Have you had a mammogram? Y N If yes, date where If no, why not? (Explain) Have you ever had breast surgery? Y N If yes, what type which breast Have you ever had a breast biopsy? Y N If yes, what type which breast Have you ever had a needle aspiration? Y N If yes, which breast Have you ever been diagnosed with breast cancer? Y N Not Sure If yes, when? Did you have breast radiation treatment? Y N Has your mother, sister s, or daughter ever been diagnosed with breast cancer? Y N Have you ever had an Oophorectomy (removal of ovaries)? Y N If yes, when? Have you ever had a Hysterectomy? Y N If yes, when? Have you ever had a tubal ligation? Y N If yes, when? Number of Pregnancies Number of Births Age at first birth If married, has your husband had a vasectomy? Y N Present Breast Problems Do you currently have any breast issues? Y N Have you detected a lump in your breast? Y N If yes, when Which breast? How long has it been present? Do you have nipple secretion? Y N If yes, which breast what color How long has it been it present? Do you have any soreness in your breast? Y N If yes, which breast? How long has it been present? Do you take birth control pills? Y N If yes, what type? Dates taken: Do you take hormone pills? Y N If yes, what type? Dates taken: What was the last date of your menstrual period? Age of first menstrual period? 3

YWCA WOMEN S HEALTH INITIATIVE We do not discriminate against any person on the basis of race, color, natural origin, sex, age, religion, or disability; in our program of services. Consent for Services By my signature below, I consent to services provided through the Women s Health Initiative Program of the YWCA of Lubbock necessary for the early detection of breast and cervical cancer. Consent for Release of Information I hereby authorize University Medical Center, Texas Tech University Health Sciences Center, Joe Arrington Cancer Center, Covenant Health Systems, Covenant Medical Group, and/or my private physician/healthcare clinic to disclose a report of any screening or diagnostic procedures done for the purpose of early detection of breast/cervical cancer to the aforementioned medical providers and /or my private physician/healthcare clinic. The disclosure of information authorized herein is made for the purpose of follow-up. Should I need further diagnostic procedures and such disclosure shall be limited to the following specific types of information: Results of clinical breast and /or cervical examination, mammography Screening results, Pap test results, biopsy results and any further diagnostic procedures necessary for the early detection of breast/cervical cancer. I agree for non-identifying demographic data to be used by the YWCA for reporting purposes. I understand that my participation in the YWCA Women s Health Initiative means that I will be asked to have additional evaluation or initiation of treatment if any abnormalities are found in my Pap test or mammogram. I agree to case management and further testing until a final diagnosis is made. By agreeing to receive services through the YWCA of Lubbock Women s Health Initiative, I understand that I am agreeing to the release of information to the Med- IT (Medical Information Tracking System) records system as well as to the YWCA of Lubbock. Client Signature Date of Signature Printed Name of Client Witness Signature (other than client) Date of Signature 4

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6 YWCA WHI

Patient Information (Patient Keeps This Page) Next Steps: Thank you for filling out the registration packet. After we receive the packet, we may call you with questions. After we verify your eligibility for our program, your information will be forwarded to the medical partner you selected. You will be contacted directly by UMC or Covenant to set up your appointment. Please allow up to ten business days to hear from them. They may have additional questions, so please be prepared for the phone call to take several minutes. After 10 business days, if you have not heard directly from UMC or Covenant, please contact them. You will need to know your date of birth and referring physician or clinic. After your appointment has been set, please call UMC or Covenant for directions, questions or to change your appointment time. Important Phone Numbers: YWCA WHI (806)687-8858 Covenant Arrington Comprehensive Breast Center (806)725-7908 UMC Dimensions (806)775-8660 For assistance getting medical insurance visit the following website: https://www.healthcare.gov/ Or call 1-800-318-2596 for questions or further assistance. 7 YWCA of Lubbock Women s Health Initiative

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