Communicating to Illiterate Populations

PART I - INITIAL VISIT ONLY

(Space to be allotted for addressograph)

HOSPITAL FACILITY _________________

DEMOGRAPHIC INFORMATION

LAST NAME: ________________

FIRST NAME: _____________________ MIDDLE INITIAL: ____

MAIDEN NAME: _______________

BIRTH DATE: ____/___/___ (yyyy/mm/dd)

PROVINCE/COUNTRY OF BIRTH: ____________________

TELEPHONE: (home) - __________________ (work) - _______________

HOME ADDRESS:

Street: ______________________
Postal Code: __________________

City/Town: _______________________

MAILING ADDRESS:

Street: ______________________
Postal Code: __________________

City/Town: _______________________

FAMILY DOCTOR:

Name: _______________________

Mailing Address: __________________
Postal Code: _____________________

N.B. MEDICARE NUMBER: ___________________________

Facility Unique Identifier: ___________ Residence Code: _________________

BACKGROUND INFORMATION

Please help us determine your health profile by answering these questions:

Have you ever had a mammogram (breast x-ray)?
Yes No
If Yes, when was your most recent mammogram?
1-2 years ago 2-3 years ago
3-5 years ago more than 5 years ago
Have you ever had a physical examination of your breasts by a doctor or other trained health professional?
Yes No
If Yes:
- When was most recent exam?
  less than 1 year ago 1-2 years ago
  2-3 years ago more than 3 years ago
- Who completed the exam?
  a doctor a nurse other trained health professional