Partners in Health Community Access Program

Health History Form Instructions

A Completed Sample Health History form has been provided for guidance. Click on the link to see the sample form.

This form will be scanned into a computer database. It is very important that the information be accurate, complete and legible.

Please remember to place today's date at the top of the form.

1) Please complete this form using blue or black ink.

2) Use block letters and numbers. Print each letter or number within the block provided.

3) Please examine and follow the Directions at the top, left hand corner of the form.

4) If the CAP Enrollee is not employed, leave the Employer & Occupation blocks blank.

5) Examples of occupations are: construction laborer, carpenter, coal miner, truck driver, restaurant worker, etc

6) When the form has been completed, white out any wrong answers and / or any stray marks on the form.

Mail this Health History scan form to the CAP IS Coordinator::

Mike Broce, BA, Research Assistant, CHERI

3200 MacCorkle Avenue, SE

Charleston, WV 25304

If you have access to the CAP website data entry program, you may enter the Health History data via the web.

1) The data entry screen for the Health History will the same as the Health History scam form.

2) The questions will be exactly the same and will appear in the same order.

3) If the CAP Enrollee is not employed, leave the Employer & Occupation blocks blank.

4) Examples of occupations are: construction laborer, carpenter, coal miner, truck driver, restaurant worker, etc.

Please check your work carefully before you hit the submit button.

	1) Please complete this form using blue or black ink.
	2) Use block letters and numbers. Print each letter or number within the block provided.
	3) Please examine and follow the Directions at the top, left hand corner of the form.
	4) If the CAP Enrollee is not employed, leave the Employer & Occupation blocks blank.
	5) Examples of occupations are: construction laborer, carpenter, coal miner, truck driver, restaurant worker, etc
	6) When the form has been completed, white out any wrong answers and / or any stray marks on the form.

	Mike Broce, BA, Research Assistant, CHERI
	3200 MacCorkle Avenue, SE
	Charleston, WV 25304

	1) The data entry screen for the Health History will the same as the Health History scam form.
	2) The questions will be exactly the same and will appear in the same order.
	3) If the CAP Enrollee is not employed, leave the Employer & Occupation blocks blank.
	4) Examples of occupations are: construction laborer, carpenter, coal miner, truck driver, restaurant worker, etc.