WISEWOMAN Enrollment & Consent Form

Name*

First NameLast Name

Date of Birth*

Date

Age in Years*

Social Security Number*

Family's annual income (before taxes)*

Number of people in the household*

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Is it okay for the WISEWOMAN program to leave a detailed voicemail on this phone?*

YesNo

Email*

example@example.com

I am also enrolled in the Montana Cancer Screening Program, which is a program that helps eligible women pay for breast and cervical cancer screenings.*

YesNo

I am interested in receiving more information about the Montana Cancer Screening Program.

YesNo

Are you of Hispanic or Latino origin?*

YesNoUnknown

What race do you primarily identify as?*

If you are multi-racial, what is the secondary race you identify as?

What is your highest level of education?*

What is the primary language spoken in your home?*

Do you own any of the following: desktop computer, laptop computer, smartphone, tablet, or portable computer?

YesNoDon't KnowDon't Want to Answer

Do you or any member of this household have access to internet?

Yes, by paying a cell phone company or internet service providerYes, without paying a cell phone company or service providerNo access to internet in the house, apartment, or mobile homeDon't knowDon't want to answer

During the last 12 months, was there a time when you were worried you would run out of food because of a lack of money or other resources?

YesNoDon't KnowDon't Want to Answer

Have you ever missed a doctor's appointment because of transportation problems?

YesNoDon't KnowDon't Want to Answer

If you are currently using childcare services, please identify the type of services you use. If not, select 'Not Applicable'

Have you had any of these childcare related problems during the past year? (Select all that apply)

What is your housing situation today?

The following will ask about how safe you feel. How often does your partner physically hurt you, insult you, or talk down to you?

If you are not currently taking medication for a chronic health condition, please skip this question. Do you ever forget to take your prescribed medication, are careless at times about taking your medication, stop taking your medication when you feel better, or stop taking your medication if it makes you feel worse?

YesNoDon't KnowDon't want to answer

WISEWOMAN Information

The Montana Cardiovascular Health Program has a grant from the Centers for Disease Control and Prevention (CDC) for WISEWOMAN heart disease services. The program helps with heart disease screenings for low-income women, ages 35-64, who don’t have health insurance, are not on Medicaid, or who are under-insured. To be a part of WISEWOMAN, the woman must be eligible for breast and cervical cancer services offered by the Montana Cancer Control Programs.

The heart disease screenings will be done three times:

1) First screening
2) Follow-up screening (you will schedule this with your WISEWOMAN doctor)
3) Third screening (12-18 months after first screening)

The screenings with your WISEWOMAN doctor will include:

Birthday, race, ethnicity, county and zip code where you live, main language you speak, etc.
Measuring your blood pressure, cholesterol, blood sugar, height, weight, and waist
Talking about any heart disease risks you have, your usual eating habits, how active you are, and if you smoke
Talking about medicines you take to lower blood pressure, cholesterol, or blood sugar
Talking about any issues you might have with housing, transportation, or access to food
Learning about how to lower your heart disease risk
Referring you, if needed, to lifestyle management programs or services to help manage heart disease risk or your social needs
NOTE: During your screening, if your blood pressure top number is more than 180 OR the bottom number is more than 120, your WISEWOMAN doctor will recheck your blood pressure within seven days.

Insurance Information

I understand that I may be billed for services not covered by my insurance or WISEWOMAN.

Confidentiality

Any information that I (the WISEWOMAN patient) share will be confidential. The information will be available only to me, my WISEWOMAN doctor, and WISEWOMAN staff. WISEWOMAN staff includes employees at the county health department, clinic, and state health department who work on the WISEWOMAN grant. Program reports will include information on groups of patients and will not identify anyone by name.

Consent to Share Health Care Information

I consent to and authorize sharing my records (screenings and referrals) with the WISEWOMAN staff for up to six months past the time when the third screening is done.

Commitment to Participate

I understand that I am agreeing to three clinic visits and participation in at least one lifestyle management program if recommended by my doctor. I agree to answer phone calls, text messages, or other ways of communicating. I understand that my participation is voluntary and that I may drop out of the WISEWOMAN program at any time. If I would like to leave the program, I will contact the program lead.

I have read the information above, talked about WISEWOMAN services, and agree to be part of the WISEWOMAN program. If I had any ask questions about WISEWOMAN, they were answered. All information I gave to WISEWOMAN staff (including whether I have health insurance) is, to the best of my knowledge, true. I give permission for Logan Health and Flathead City-County Health Department to share my patient information for the purpose of WISEWOMAN.*

I agreeI do not agree

Signature*

WISEWOMAN Enrollment Form

Eligibility Enrollment Information

Demographic Information

Social Determinants of Health Screening

Informed Consent