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This algorithm in English and Spanish can be used by health center program grantees as part of the intake process to identify farmworker patients.  It incorporates HRSA’s 2012 revised definition of migrant and seasonal farmworkers.

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“As of January 1, 2012, the Centers for Medicare & Medicaid Services (CMS) requires that a health risk assessment (HRA) be completed as part of the Medicare annual wellness visit. Efforts by the AAFP and others to persuade CMS to delay the HRA were unsuccessful, and the requirement became effective without a compliant form for physicians to use.”“To fill this void, the AAFP's practice improvement journal Family Practice Management (FPM) published a questionnaire developed by HowsYourHealth.org. The questionnaire meets the requirements for the HRA and can help you identify health behaviors and risk factors in patients.”
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A sample Depo-Provera interval history form in English and Spanish.
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Adult health history qustionnaire with a number of social and behavior related questions.
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A sample oral anticoagulation flow sheet.
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A sample diabetes flow sheet.
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A sample diabetes flow sheet.
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A diabetes outpatient form for nursing encounters.
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A sample asthma visit flow sheet.
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An employee performance review form. Includes a rating system, evaluation & goals and verification of review.

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MCN recommends screening for migrant status at every clinic visit. This bilingual tool is designed to help clinic staff identify migrant and seasonal farmworkers.

Clinic staff should verbally question client at every visit and determine status (migrant farmworker, seasonal farmworker, aged/disabled farmworker, not a farmworker) based on client’s responses.

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THIS AGREEEMENT made effective the date of signing below, between ****** COMMUNITY HEALTH CENTER, INC., hereinafter referred to as “***,” and *****, hereinafter referred to as “****.”........

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Usted y su bebe pregnancy pamplet.

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Two-page form used to report accidents or incidents in the clinic.
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Policies such as this will eliminate accidental or innocent destruction of important documentation. It is important for administrative personnel to know the length of time records should be retained to be in compliance. 

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Appointment for first visit should be scheduled within 8 weeks of gestation. The first appointment is scheduled with perinatal nurse.
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Pediatric health maintenance checklist, 2 weeks to 6 years.
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A series of health maintenance forms that cover adolescents and children from 1 week to 18 years.
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The U.S. Department of Health and Human Services has released an updated and improved version of the Surgeon General's internet-based family health history tool. The new tool makes it easier for patients to assemble and share family health history and can also help practitioners make better use of health history information. For more detailed information about the new tool, please visit the website listed.
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This questionnaire may be used as part of the review of systemswith patients. The clinician might begin, "I need to ask a fewshort questions about your sexual health in order to be thoroughin providing your medical care."
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A Spanish translation of the Adult Medical History Form.
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A Spanish version of the Adult Medical History Form.
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A sample oral contraceptive interval history form in English and Spanish.
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A Spanish translation of the 1-page sample social history form.

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This resource provides a straightforward tool to use to develop effective hepatitis risk assessment with adult clients through your clinic charting system.

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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.

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One page tool to use in evaluating the possibility of physical abuse.

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A 2-page sample prenatal health history form.
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