If yes, please specify who and their relation to you and provide a copy of document to CHWP.
What are your top 3 goals for your first appointment?
Goal #1Goal #2Goal #3
Because we are partially funded by a federal grant, we are asked to collect income information. Please determine the number of persons in your household and check your annual (yearly) income range. This information is for generalized reporting regarding the health center. NO PERSONAL INFORMATION IS SHARED, but we may recommend completing our sliding fee scale application based on your response.
Please check any condition you have been diagnosed with by a medical professional/provider.
Please list all medications, vitamins, supplements that you are currently taking. Please bring medications.
Please list medication, food, health related allergies and reactions. If reaction not known, enter "unknown".