APPLICATION

                                                                               Your

Your Name_______________________________        Social Security #________________________

Date of Birth_____/________/_19_____        Sex    ____Male    ____Female

Race    _____ Caucasian    ____ African American   _____ Asian American   ____ Hispanic American

            _____ Other       

Address_______________________________________________________________________________

____________________     _______________                             ___________________________   

(City)                                      (Zip Code)                                                         (County)

Home Phone # __________________________        Alternate Phone #___________________________

Please check all that apply  

_____  I am a resident of Jefferson County.

_____  I have no health care insurance.

_____  I do not have a primary care physician.

                Have you been diagnosed with any of the following chronic conditions:

____ Congestive Heart Failure                                         _____ Diabetes

____ Emphysema                                                                               _____ High Blood Pressure

____ Sickle Cell                                                                   _____ Asthma

____ None Apply                                                Chief Complaint__________________________________

An appointment has been scheduled at:

Chris McNair Health Center____________________________________________

Pratt City Health Center_______________________________________________

Western Health Center________________________________________________

Enrollment Date: _________________________