Breast Cancer Walk Intake form for breast cancer screening appointments About YouFirst we will collect some basic information about you. Primero, recopilaremos información básica sobre usted.Your Legal Name(Required) First Last Tu nombre legalDate of Birth(Required) MM slash DD slash YYYY Fecha de nacimientoEthnicity(Required)American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhiteHispanic or LatinoEtnicidadPrimary Language Spoken(Required)EnglishEspañolOtherIdioma principal habladoDo you need an interpreter?(Required)Please select an optionYesNo¿Necesitas una intérprete?Gender(Required)Please select an optionMaleFemaleTransgenderGéneroAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code DIRECCIÓNHow Can We Reach You?We will review your information and follow up. How can we get in touch? Revisaremos su información y le daremos seguimiento. ¿Cómo podemos ponernos en contacto?Your Email Address Email Address Confirm Email Address Su dirección de correo electrónicoYour Phone(Required)Tu número de teléfonoBest time of day for an appointment(Required)Please select an optionSelect a time of dayMorningsAfternoonsAnyIf we need to schedule an appointment, what time usually works best for you? Si necesitamos programar una cita, ¿a qué hora suele ser mejor para usted?Preferred day for an appointment(Required)Please select an optionMondayTuesdayWednesdayThursdayFridayAny dayIf we need to schedule an appointment, what day usually works best for you? Si necesitamos programar una cita, ¿qué día suele ser mejor para usted?Is transportation an issue with getting to an appointment?(Required)Please select an optionNoYes¿El transporte es un problema para llegar a una cita?How did you hear about us?(Required)In person eventInside BusBus Stop or ShelterPost Card in the communityText to PhoneSocial MediaGospel concertWord of mouthInsurance companyCDPHP Case ManagementMVP Case ManagementHighmark Case ManagementOther¿Cómo te enteraste de nosotras?Are you willing to participate in a future promotion?(Required)YesNoWe may ask you for a testimonial or ask to take/use your photo. Es posible que le pidamos un testimonio o le solicitemos tomar/usar su foto.Health Screening QuestionsPlease answer these Preliminary Screening Questions so that we can better serve you. Responda estas preguntas de evaluación preliminar para que podamos brindarle un mejor servicio.Insurance?(Required)Please select an optionCDPHPMVPHighmarkNoneOther ¿Seguro?Name of Insurance?(Required)¿Nombre del seguro?Have you seen a Primary Care physician within the last 3 years?(Required)Please select an optionNoYes¿Ha consultado a un médico de Atención Primaria en los últimos 3 años?What is the name of your Primary Care physician?(Required)¿Cómo se llama su médico de Atención Primaria?Do you have a gynecologist?(Required)Please select an optionYesNo¿Tienes una ginecóloga?What is the name of your gynecologist?(Required)¿Cómo se llama tu ginecóloga?Last mammogram(Required)Please select an optionless than a yearover 1 year agoover 2 years agodon't rememberneverúltima mamografíaHave you ever had an abnormal mammogram?(Required)Please select an optionYesNo¿Alguna vez ha tenido una mamografía anormal?Where was your mammogram image taken?(Required)¿Dónde se tomó la imagen de su mamografía?Is there a family history of breast cancer?(Required)Please select an optionNoYes¿Existen antecedentes familiares de cáncer de mama?Are you within 10 years of the age when your family member was diagnosed?(Required)Please select an optionNoYes¿Tiene usted 10 años de edad cuando su familiar fue diagnosticado?Any nipple discharge or have you noticed a breast mass?(Required)Please select an optionYesNo¿Alguna secreción del pezón o has notado una masa en el seno?
