APPENDIX B

ELIGIBILITY CHECKLIST


PROCEDURE:

  1. Ascertain the eligibility of the caller using the checklist below.
  2. If the woman is eligible, schedule an appointment. Ask her to:
    • bring her Medicare card, the name and address of her family physician or name of designated Health center the day of her visit. If she does not have a physician, advise her that she will be asked to select one from a list of physicians willing to accept clients from the screening service.
    • not apply any deodorant or body powder the day of her visit.
  3. If the woman is ineligible due to a temporary condition, she may--if feasible--be provided with an appointment date that respects the time stipulation(s) specific to her condition(s).
  4. If the woman is permanently ineligible, explain that:
    • follow-up and management of women who have had breast cancer is best provided by their personal physician; and/or
    • breast enlargement surgery requires specialized mammography positioning that is beyond the scope of screening. Mammography for these women should be arranged through their physician.
  5. If the woman is a returning screenee who was last examined at another N.B. screening site and it is not feasible for her to return to the previous site, initiate a request for her file through hospital facility clinical records.
ELIGIBILITY CHECKLIST ELIGIBLE
(if all checked)
INELIGBILE
(if any checked) (P) = permanently
What is your current age? graphic of checkbox ≥ 50 years and ≤ 69 years graphic of checkbox < 50 years or > 69 years
Are you a New Brunswick resident? graphic of checkbox Yes graphic of checkbox No
Have you had a mammogram in the last year? graphic of checkbox No graphic of checkbox Yes
Do you now have any breast symptoms or complaints such as a solitary lump or nipple discharge? graphic of checkbox No graphic of checkbox Yes (Refer to GP)
Have you had breast cancer? graphic of checkbox No graphic of checkbox Yes (P)
Have you had breast enlargement surgery, such as implants or injections? graphic of checkbox No graphic of checkbox Yes (P)
Have you been breastfeeding in the last 3 months? graphic of checkbox No graphic of checkbox Yes
Is there a possibility that you are currently pregnant? graphic of checkbox No graphic of checkbox Yes