Download Western NC Community Health Services, Inc

Western NC Community Health Services, Inc.
ENROLLMENT APPLICATION
Read CAREFULLY. Provide ALL information and answer ALL questions. If ANY information is missing or a
question is unanswered, the application will be discarded. PRINT legibly. Use an ink pen. 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. Unless instructed otherwise, submit only
ONE application per person. Submitting more than one application for the same person will delay the process. If the
application is COMPLETE, expect to hear from us 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. Si deja alguna pregunta sin contestar su aplicación no será
procesada. 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. Favor de entregar solo una aplicación por persona. 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/ataque al corazón? 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:____________________