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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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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.

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Two-page form specific to an individual coming into the clinic for an initial hypertension visit.
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Two-page form specific to an individual coming into the clinic for an initial asthma visit.
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One-page adult/adolescent general assessment form.
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Form to collect insurance information from new patients.
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A sample medication record for the medical chart.
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Seven page document that provides a sample/template emergency preparedness plan.

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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.

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A few sample dental chart review forms/templates. 

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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.
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Psychosocial Assessment form to be used by providers.
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Child/Adolescent personal history form designed for an individual to fill out prior to seeing a therapist.
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Adult personal history form designed for an individual to fill out prior to seeing a therapist.

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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".
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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.
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This is an integrated risk assessment form for STD, HIV, and hepatitis A, B, and C. The risk assessment form is designed to assess at-risk clients within your clinic and determine the services they should receive. This form is designed to be self-administered. Once the client has completed the form, it should then be reviewed by the clinic staff to determine the services the client is eligible to receive. In addition to screening, testing, and/or vaccine services, all clients should be offered appropriate counseling and educational materials tailored to their specific risks.

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A one-page diabetes foot screening form.
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A sample asthma assessment form.
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