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WOMEN'S WAY DEMOGRAPHICS (City of BIsmarck)

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BROWSE CITY OF BISMARCK (ND) FORMS

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WOMEN'S WAY DEMOGRAPHICS
NORTH DAKOTA DEPARTMENT OF HEALTH
CANCER PREVENTION AND CONTROL
SFN 54024 (5-2017)
Page 1 of 2
IDENTIFICATION & ENROLLMENT
Enrollment Site County of Enrollment
Type
Enrollment Re-Enrollment
Date (MM/DD/YYYY)
Appointment Location/Provider
Appointment Date (MM/DD/YYYY)
Name (Last, First, Middle Initial)
Social Security Number *
Alternate ID Number
Maiden Name
Any Other Last Name Used
Date of Birth (MM/DD/YYYY)
Race(s) (check all that apply)
White
Black
Asian
Pacific Islander
American Indian
Native Hawaiian
Eskimo
Unknown
Hispanic/Latino Origin
Yes No Unknown
MAILING ADDRESS
Street or P.O. Box City County State ZIP Code
Home Phone Number
Cell Phone Number
Work Phone Number
Email
ALTERNATE ADDRESS (Secondary)
Street Address City
State ZIP Code Alt Telephone No.
DEMOGRAPHICS
Client Status
1. Active 2. Inactive 3. Out of Area 4. Temp Inactive
5. Deceased
Date of Status Change (MM/DD/YYYY)
Status Notes
Visit Type
1. Initial
2. Re-Screen (Annual)
3. Re-Screen (Follow-up)
Health Insurance (check all that apply)
1. None
2. Health Insurance 3. Medicare A 4. Other: 5. Medicaid
Referred to:
Marketplace Medicaid Expansion Other:
Please provide a copy of insurance card (front and back).
Name of Insurance Company Name of Policyholder
Policyholder Date of Birth (MM/DD/YYYY)
Insurance Benefit Plan Number Insurance Company Telephone Number Coverage Dates
Household Status
1. Never Married 2. Married 3. Widowed 4. Divorced/Separated 5. Domestic Partner 6. Other:
Are you a smoker/tobacco user?
1. No 2. Former
3. Yes
Are you interested in quitting at this time?
1. Yes 2. No
3. Not Applicable
Are you exposed to second-hand smoke?
1. Yes 2. No
Referral offered?
1. Yes 2. No 3. Declined
4. Not Applicable
Comments
Education
1. 8th Grade or Less
2. Some High School
3. High School Graduate/GED
4. Some Technical School
5. Technical School Graduate
6. Some College
7. College Graduate
8. Unknown
Number Living in Household (including yourself) Total Gross Monthly Household Income (before taxes)
Referral Source (check all that apply)
2. Provider
4. WW/BCCP Reminder
6. Radio Campaign
8. Other:
7. Newspaper
5. TV Campaign
3. Outreach
1. Self
Page 2 of 2
SFN 54024 (5-2017)
Previous Mammogram?
1. Yes 2. No
If Yes, Date of Last Mammogram (MM/DD/YYYY)
Implants?
1. Yes 2. No
Noticed Changes in Breast?
1. Yes 2. No
If Yes, Specify Changes
1. Skin Different
2. Lump
3. Nipple Discharge
4. Nipple Inversion
5. Other:
Do you have a history of breast cancer in your family? (check all that apply)
1. Mother 2. Sister 3. Aunt 4. Daughter 5. Grandmother 6. None 7. Unknown 8. Self
Have you been taught breast self-exam?
1. Yes 2. No
Previous Pap Test?
1. Yes 2. No
If Yes, Date of Last Pap
History of Abnormal Paps?
1. Yes 2. No
Have you had a Hysterectomy?
1. Yes 2. No
If Yes,Reason for Hysterectomy
1. Cervical Cancer 2. Unknown 3. Cervical Pre-Cancer 4. Non-Cancer
Do you still have a cervix?
1. Yes 2. No
3. Unknown
I verify that, to the best of my knowledge, all information I have provided to Women's Way is true and accurate.
Signature
Date (MM/DD/YYYY)
Contact Person (list someone NOT in your household, i.e., relative, neighbor, friend, etc.)
Relationship to the Applicant Telephone Number
Questions? Please contact your Enrolling Site Office at 800.44 WOMEN or 701.328.2306
According to the Privacy Act of 1974, this is to let Women's Way clients know that disclosure of a social security number to Women's Way is voluntary and
it is requested for identification purposes only. Failure to disclose this information will not affect participation in this program.
Date of Birth (MM/DD/YYYY)
Name (Last, First, Middle Initial)
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WOMEN'S WAY DEMOGRAPHICS (City of BIsmarck)

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Completed 16 January 2021

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