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Breast and Cervical Cancer Screening Eligibility Form

Assess whether a patient meets the requirements for a breast and cervical cancer screening program, and record her medical history along with her consent.

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Page 1

Name*

First Name

Last Name

Date of birth*

What is your age?

Family's yearly income before taxes?

Number of people in household?

Phone number*

Is it okay to leave messages about eligibility/appointments at these numbers?*

Yes No

Address

Street Address

City

State / Province

ZIP / Postal Code

What county do you live in?

Are you Hispanic?*

Which race(s) best describe you?*

White Black/African American Asian Native American Pacific Islander Other

Do you have Medicare Part B?*

Yes No

Do you have Medicaid?*

Yes No

Do you have health insurance?*

Yes No

If yes, name of insurance company

What is the deductible amount?

Have you been referred to the Marketplace for health insurance or Expanded Medicaid plans?

Yes No

Date referred

Are you having any breast problems?

Yes No

Have you ever had a mammogram?

Yes No

Date of last mammogram

Do you have breast implants?

Yes No

Do you have a personal or family history of breast cancer?

Yes No

Have you ever had a Pap test?

Yes No

Date of last Pap test

Have you had a hysterectomy?

Yes No

If yes, was it due to cervical cancer?

Yes No

If yes, do you still have a cervix?

Yes No

Are you up to date on your HPV vaccinations?

Yes No

Are there any circumstances that might prevent you from receiving your cancer screening services?

Transportation Childcare Work schedule Language barrier Cost Other

Do you use tobacco?

Yes No

How did you hear about the program? (Check all that apply)

Doctor referral Clinic Friend or family Community event Social media Other

Page 2

I certify that the information provided above is true and accurate to the best of my knowledge.

Name*

First Name

Last Name

Date*

Signature*

Sign here

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