Download Western NC Community Health Services, Inc

Western NC Community Health Services, Inc.
ENROLLMENT APPLICATION
Read CAREFULLY. Follow EVERY instruction. Submit ONLY ONE page. Provide ALL the information
requested. Answer ALL questions. PRINT legibly in ink. The application may be submitted by U.S. mail to:
Western NC Community Health Services, PO Box 338, Asheville, NC, 28802. It may also be dropped in the
box labeled “Enrollment Applications Only”, located outside the main entrance (west side) of the Minnie Jones
Health Center, 257 Biltmore Ave., Asheville, NC, at any time. If the application is completed fully and
correctly, expect to hear from us by U.S. mail within 30 days.
First Name: __________________________ Mid Initial:___
Last Name:________________________________
Date of Birth:_________________________ Sex at Birth: Male__ Female__
STREET ADDRESS (no PO Box):___________________________________________________________________
Zip Code:___________________ Primary Contact Phone # from 9-5: (__________)__________________________
1) Is applicant known to have cancer (now or in the past)? Yes__ No__
2) Is applicant known to have had a heart attack/heart surgery? Yes__ No__
3) Is applicant known to have had a stroke? Yes__ No__
4) To the applicant’s best knowledge, is he or she REQUESTING TREATMENT for (answer ALL questions):
 High Blood Pressure?
Yes__ No__
 Diabetes?
Yes__ No__
 Thyroid Disorder?
Yes__ No__
 Chronic Asthma/Bronchitis?
Yes__ No__
 Epilepsy/Seizures?
Yes__ No__
 Fibromyalgia/Chronic Pain?
Yes__ No__
 Behavioral health (e.g., Depression, Anxiety, OCD, PTSD)? Yes__ No__
5) As of today, is the applicant TAKING PRESCRIPTION MEDICATIONS for (answer ALL questions):
 High Blood Pressure?
Yes__ No__
 Diabetes?
Yes__ No__
 Thyroid Disorder?
Yes__ No__
 Chronic Asthma/Bronchitis?
Yes__ No__
 Epilepsy/Seizures?
Yes__ No__
 Fibromyalgia/Chronic Pain?
Yes__ No__
 Behavioral health (e.g., Depression, Anxiety, OCD, PTSD)? Yes__ No__
6) Comments (optional):_______________________________________________________________________________
Signature:________________________________________
Date:______________________
Western NC Community Health Services, Inc.
FORMULARIO DE REGISTRO
Favor de contestar TODAS las preguntas. Escriba en letra de molde. No use lápiz. Puede enviar la aplicación
por correo a: Western NC Community Health Services, PO Box 338, Asheville, NC, 22802. También puede
echar la aplicación en el cajón negro que esta fuera de la puerta principal de la clínica Minnie Jones, 257
Biltmore Ave, Asheville, NC. Si la aplicación es entregada de acuerdo a estas instrucciones, puede esperar
nuestra respuesta dentro de treinta (30) días.
Nombre___________________________ Primer Apellido (paterno):_________________________________
Fecha de nacimiento:___________________________ Sexo de nacimiento: Hombre__ Mujer__
Dirección física (no PO Box):________________________________________________________________
Código Postal:___________________ Teléfono de contacto de 8 a 5: (________)______________________
1) Sabe si el solicitante ha tenido cáncer? Sí__ No__
2) Sabe si el solicitante ha tenido un infarto cardiaco/cirugía de corazón abierto? Sí__ No__
3) Sabe si el solicitante ha tenido un derrame (sangramiento) cerebral? Sí__ No__
4) Está SOLICITANDO TRATAMIENTO para (conteste todas las preguntas):

Presión arterial alta?
Sí__ No__

Diabetes?
Sí__ No__

Trastorno de la tiroides?
Sí__ No__

Asma o bronquitis crónica? Sí__ No__

Epilepsia o convulsiones?

Depresión/ansiedad/nervios? Sí__ No__
Sí__ No__
5) En estos momentos está TOMANDO MEDICAMENTOS para (conteste todas las preguntas):

Presión arterial alta?
Sí__ No__

Diabetes?
Sí__ No__

Trastorno de la tiroides?
Sí__ No__

Asma o bronquitis crónica? Sí__ No__

Epilepsia o convulsiones?

Depresión/ansiedad/nervios? Sí__ No__
Sí__ No__
6) Algo más? (opciónal):_______________________________________________________________________
Firma:___________________________________________
Fecha:____________________