APPENDIX B
ELIGIBILITY CHECKLIST
PROCEDURE:
- Ascertain the eligibility of the caller using the checklist below.
- 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.
- 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).
- 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.
- 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? |
≥ 50 years and ≤ 69 years |
< 50 years or > 69 years |
Are you a New Brunswick resident? |
Yes |
No |
Have you had a mammogram in the last year?
|
No |
Yes |
Do you now have any breast symptoms or complaints such as a solitary
lump or nipple discharge?
|
No |
Yes (Refer to GP) |
Have you had breast cancer? |
No |
Yes (P) |
Have you had breast enlargement surgery, such as implants or injections?
|
No |
Yes (P) |
Have you been breastfeeding in the last 3 months?
|
No |
Yes |
Is there a possibility that you are currently pregnant?
|
No |
Yes |
|