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Cancer Screening Referral Form
Home
Health & Wellness
Women’s Health
Cancer Screening Referral Form
Cancer Screening Referral Form
Fill out the form below to be referred to healthcare providers for no-cost cervical and/or breast cancer screening within Massachusetts. This Women's Health Network Program is offered in partnership with the Family Health Center of Worcester, which receives funding from MA Department of Public Health. All information provided is accessible to the MA DPH. Requests for free screenings are referred to Family Health Center, 26 Queen St., Worcester.
Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Address Type
Home
Work
Other
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Type
Home
Work
Mobile
Phone
Demographic Information
Hispanic Ethnicity?
Yes
No
Unknown
Race (check all that apply)
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Unknown
Other
Country of Birth
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
U.S. Citizen?
Yes
No
In no, how many years have you lived in the U.S.?
Education Level
Less than 9th grade
Some high school
High school or GED/HiSET
Some college, no degree
Associate degree
Bachelor degree
Graduate/Prof. Degree
Unknown
Needs Assessment
Special Needs (check all that apply)
Hearing
Handicap Access
Help with Forms
Learning Disability
Help Making Appointments
Speech
Other (please describe below)
If you selected "other", please describe:
Primary Langauge
English Fluency
None
Somewhat fluent
Unknown
Interpreter Needed?
Yes
No
Barrier Assessment
Do you have a preference for male or female medical staff?
No preference
Yes, female
Yes, male
Do your visits need to be scheduled so that others can accompany you? (example: spouse, family member, etc.)
Yes
No
Do you have a religious preference?
Muslim
Other
Does seeking treatment conflict with your religious beliefs?
Yes
No
Will you be seeking complementary or alternative care, in addition to a physician recommended plan? (acupuncture, homeopathy, etc.)
Yes
No
Does patient need transportation?
Yes
No
Does client need child/elder care?
Yes
No
Unknown
Employer Issues?
Yes
No
Unknown
Limited phone access?
Yes
No
Unknown
No permanent home?
Yes
No
Unknown
Fear?
Yes
No
Unknown
Distance to provider?
Yes
No
Unknown
Other medical condition?
Yes
No
Unknown
Any other barriers to the patient receiving care?
Yes
No
Unknown
If other barrier(s), please describe here:
Income and Health Insurance Eligibility
Client currently insured?
Yes
No
Coverage?
Commonwealth Care
Commonwealth Choice
Medicare part A only
Health Safety Net
Mass Health
Medicare A & B
Private
Mass Health Limited
What is your household income before taxes?
Income timeframe?
Annual
Monthly
Weekly
How many people live on this income?
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