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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:____________________