x
A series of health maintenance forms that cover adolescents and children from 1 week to 18 years.
Download Resource
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.
Links
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."
Download Resource
A Spanish translation of the Adult Medical History Form.
Download Resource
A Spanish version of the Adult Medical History Form.
Download Resource
A sample oral contraceptive interval history form in English and Spanish.
Download Resource

A Spanish translation of the 1-page sample social history form.

Download Resource

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

Download Resource

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.

Download Resource

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

Download Resource
A 2-page sample prenatal health history form.
Download Resource

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.

Download Resource
Two-page form specific to an individual coming into the clinic for an initial hypertension visit.
Download Resource
Two-page form specific to an individual coming into the clinic for an initial asthma visit.
Download Resource
One-page adult/adolescent general assessment form.
Download Resource
Form to collect insurance information from new patients.
Download Resource
A sample medication record for the medical chart.
Download Resource

Seven page document that provides a sample/template emergency preparedness plan.

Download Resource

The Workbook provides a process that can support state, local,and tribal planners as they advance in their efforts to reach all populations—and specifically, special populations—in day-today communication and during crisis or emergency situations.

The Workbook is divided into three primary sections, each representing a major stage in the process of communicating with special populations,and provides a baseline of research plus selected resources that should substantially reduce the work required of health departments to begin this process.

Links

A few sample dental chart review forms/templates. 

Download Resource
This policy is created to outline the process for the management and eventual discharge from service of difficult patients. This includes those who are perceived to be difficult with respect to recurrent hostile behavior, inappropriate use of FHC services, excessive non-compliance (including financial obligations), inappropriate use of controlled substances, or other patterns of behavior that represent excessive lack of respect or responsibility on the part of the patient.
Download Resource
Psychosocial Assessment form to be used by providers.
Download Resource
Child/Adolescent personal history form designed for an individual to fill out prior to seeing a therapist.
Download Resource

Adult personal history form designed for an individual to fill out prior to seeing a therapist.

Download Resource
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".
Download Resource
To promote the improvement in the quality of the assessment and care of patients, enhance the appropriate utilization of health care services, and to enhance the value of health care services.
Download Resource