download the application yourself. - Pinellas County Health ...

PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS- ANY BLANKS MAY
DELAY YOUR APPOINTMENT
Name of someone who can always reach you: (Last, First) _______________________
Relationship to you ____________________________________
Phone number of the person who can always reach you: _______________
**This number should not be the same as your home or work**
How often do you consume Tobacco? Daily some days Not at all Decline to answer
Have you had breast cancer? No Yes
Have you had invasive cervical cancer? No Yes
If yes, please explain_______________________________________________________
Has anyone in your family had breast cancer? No Yes
If “yes” circle one
Mother/sister/daughter/other ________________________________
Have you had a mammogram before? No Yes If yes, when was the last one?
_______/____ (Month/Year)
Where did you have your last mammogram? ______________________________________
(Name of Facility)
Have you had a hysterectomy? (Have you had surgery to remove your uterus & cervix?)
No Yes If yes, date of surgery _______/________ (Month/Year)
*If yes, BCC cannot provide a pap smear, per grant guidelines*
Have you had a pap test before? No Yes If yes, when was your last one _______/____
Month Year
Were the results of your last Pap test normal? No Yes
Do you have breast implants? No Yes
Are you having any breast problems? No Yes
If yes, please list what breast problems you are having: (Please be as specific as
possible)
__________________________________________________________________________
__________________________________________________________________________
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