• For an APPOINTMENT Call:
    (562) 867-7999
    Toll Free:
    (866) SEE-JWCH | (866) 733-5924

Wesley Health Centers Initial Health Assessment Forms

The following are Initial Health Assessment forms for you to complete before seeing your Wesley Health Centers doctor. Please click the one that applies to you and bring it to your visit.

Forms in English

English, age 0-6 months

English, age 7-12 months

English, age 1-2 years

English, age 3-4 years

English, age 5-8 years

English, age 9-11 years

English, age 12-17 years

English, Adult

English, Senior

Formularios en Español

Spanish, age 0-6 months

Spanish, age 7-12 months

Spanish, age 1-2 years

Spanish, age 3-4 years

Spanish, age 5-8 years

Spanish, age 9-11 years

Spanish, age 12-17 years

Spanish, Adult

Spanish, Senior

The Health Resources and Services Administration (HRSA) consider JWCH Institute, Inc. / Wesley Health Centers and its providers as Public Health Services employees, providing malpractice liability protection under the Federal Tort Claims Act (FTCA). This health center is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).

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