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.