Get the free WISEWOMAN Screening Form - michigancancer

WISEMAN Screening Form Screening Date LCA Name Screening Site Last Name First Name Clinical Measurement Result Weight (pounds) Middle Initial Birth Date Categories and Protocols for Medical Referral

How to fill out wisewoman screening form

How to fill out a WiseWoman screening form:

1. Start by obtaining the form from a healthcare provider or downloading it from a trusted website.
2. Carefully read the instructions provided on the form to ensure you understand the requirements and how to complete each section accurately.
3. Begin by entering your personal information, including your full name, date of birth, address, and contact details. Make sure to double-check the accuracy of this information.
4. Move on to the medical history section of the form. Provide details about any pre-existing medical conditions, surgeries, and allergies you may have. It's essential to be honest and thorough when filling out this section.
5. Next, answer questions related to lifestyle habits such as smoking, alcohol consumption, physical activity level, and nutrition. Provide accurate information to help healthcare professionals assess your overall health.
6. The form may also include questions about your family medical history. Take your time to provide accurate information about any hereditary conditions that may be relevant.
7. Some forms may have a section dedicated to reproductive health and questions about menstrual cycles or pregnancies. Answer these questions accordingly if they are included.
8. If the form requires you to provide your insurance or Medicaid information, ensure that you provide the correct details.
9. Finally, carefully review the completed form to ensure all information is accurate and legible. Make any necessary corrections or additions before submitting it.
10. Once you have filled out the form, return it as instructed by your healthcare provider or follow the provided submission guidelines.

Who needs a WiseWoman screening form?

1. Women who are interested in receiving preventive health services and support.
2. Individuals who are eligible for the WiseWoman program, which typically targets low-income, uninsured, or underinsured women aged 40 to 64.
3. Women who may have risk factors for cardiovascular diseases, such as high blood pressure, high cholesterol, or being overweight.
4. Those who are seeking a comprehensive health assessment to evaluate their risk factors and make informed decisions about their health.
5. Women who desire guidance on maintaining a healthy lifestyle, including advice on nutrition, physical activity, and smoking cessation.

Overall, the WiseWoman screening form is targeted towards women who could benefit from the WiseWoman program and are willing to share relevant information about their health to receive appropriate support and preventive care.

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