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Domestic Violence Screening Low Literacy Form
This is a one page tool used by community health workers to evaluate individuals for family violence. The tool is designed for use with low literacy populations and uses pictures instead of words to communicate.
Files
- Icon Form English2.pdf( 3,114.94 Kb )
- Icon Form Spanish.pdf( 3,260.76 Kb )
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Evaluation Tool for Physical Abuse, English and Spanish
One page tool to use in evaluating the possibility of physical abuse.
Files
- Evaluationfor Physical Abuse.pdf( 748.65 Kb )
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Hepatitis Charting
This resource provides a straightforward tool to use to develop effective hepatitis risk assessment with adult clients through your clinic charting system.
Files
- Hepatitis Charting Handoutstd.pdf( 5,754.92 Kb )
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"Keep It With You" (KIWY) Personal Medical Information Form
The "Keep It With You" (KIWY) Personal Medical Information Form is intended to be a voluntary and temporary record that lists medical care and other health information for people who need care during disasters and similar situations.
Files
- Kiwy.pdf( 722.89 Kb )
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Adolescent and Child Health Maintenance Forms
A series of health maintenance forms that cover adolescents and children from 1 week to 18 years.
Files
- Adolescent Child Exam.pdf( 2,277.80 Kb )
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Adolescent Self-Report (ages 13-17)
Adolescent self-report which states that it is to be used in order to "help counselors understand--in your own words--why you are here and what difficulities you might be having".
Files
- Adolescent Self Report.doc( 414.72 Kb )
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Adult Health History Questionnaire
Adult health history qustionnaire with a number of social and behavior related questions.
Files
- Adult Health History Q.pdf( 5,202.04 Kb )
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Adult Medical History Form1-SPANISH
A Spanish version of the Adult Medical History Form.
Files
- Historiadesaluddeladulto.doc( 614.40 Kb )
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Adult Medical History Form2-SPANISH
A Spanish translation of the Adult Medical History Form.
Files
- Historia Medica.doc( 634.88 Kb )
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Adult Personal History (ages 18 and over)
Adult personal history form designed for an individual to fill out prior to seeing a therapist.
Files
- Adult History Form.doc( 931.84 Kb )
