PHPR Forms and Teaching Sheets

Forms Listing

General

• CH-3A Service/Progress Notes
• CH-12 Form Instructions
• CH-12 (Rev. 01/09) Misc. Screening and Lab Tests
• CH-13 and CH-14 Instructions
• CH-13 Health History and Physical Exam (Rev. 9/02)
• CH-14 Interval Health History and Physical Exam Form (Rev. 9/02)
• CH-23 (rev. 7/06) Authorization for Release/Acquisition of Patient Information
• CH-23 Spanish
• CH-23 Instructions
• EM-1 Emergency Flow Sheet
• HHS-117 Telephone Order Form Instructions
• HHS-17 Telephone/Verbal Order
• H&P 13 Initial (Adult) Rev.01/12
• H&P 13 Initial (Pediatric) Rev. 07/11
• H&P 13 Initial Instructions 7/11
• H&P 14 Interval (Adult) Rev. 01/12
• H&P 14 Interval (Pediatric) Rev. 07/11
• H&P 14 Interval Instructions 7/11

Cancer

• ACH-16 Breast Cancer Screening Form (Rev. 01/09)
• ACH-58 Cancer Screening Form (Rev. 01/09)
• ACH-100 Mammogram Log (Rev. 1/11)
• ACH-259 (rev. 1/11) Pap Log

Diabetes

• DSMT-1 Pre/Post Class Feedback Form

Domestic Violence

• DV/SA-1 Domestic Violence/Sexual Assault Documentation Form

Family Planning

• ACH-264-B (Rev. 7/06) Consent for Deferring a Physical Exam
• ACH-264-B (12/04) Spanish
• ACH 280 Consent for IUD Insertion or Removal (6/98)
• ACH 280 Consent for IUD Insertion (Spanish)
• ACHI-9 Healthier Lifestyles for Family Planning (7/11)
• ACHI-9 Spanish (7/11)
• ACHI-12 DES Exposure (4/06)
• BC-1 Resupply Visit Form
• BC-1 Resupply Visit Form Instructions
• FP-1 Consent Form Instructions
• FP-1 Consent Form (Rev. 1-10)
• FP-1 Informed Consent, Spanish (Rev. 1/10)
• FP-2 Depo-Provera Consent
• FP-2 Depo Provera Consent, Spanish
• FP-3 Consent for Insertion of Implanon
• FP-3 Consent for Insertion of Implanon Spanish
• FP-4 Consent for Removal of Implanon
• FP-4 Consent for Removal of Implanon Spanish
• PT-1 Pregnancy Test Visit Form
• PT-1 Pregnancy Test Visit Form Instructions
• Sterilization Consent Form
• Sterilization Consent Form, Spanish

Growth Charts

• Automated Growth Charts
• Growth Chart Instructions
• MCH-1 Boys birth to 36 months
• MCH-2 Girls birth to 36 months
• MCH-3 Boys 2 to 20 years
• MCH-4 Girls 2 to 20 years

Health Risk Assessments

• ACH-90 Baby, birth to 12 months
• ACH-90 Spanish
• ACH-91 Child 12 months to 6 years
• ACH-91 Spanish
• ACH-92 Child 7 thru 10 years
• ACH-92 Spanish
• ACH-93 Adolescents 11 thru 20 years
• ACH-93 Spanish
• ACH-94 Adults 21 and older, all pregnant, all FP patients
• ACH-94 Spanish
• HRA Instructions (Rev. 1/08)

Immunization

• CH-2A Form Instructions
• CH-2A Immunization Record (Rev.1/11)
• IMM-1 Instructions
• IMM-1 Informed Consent for Vaccines
• IMM-1 Informed Consent for Vaccines, Spanish

Lead

• Lead-1 Initial Home Visit Form (Rev. 7/09)
• Lead-2 Follow-up Home Visit Form (Rev. 7/09)
• Lead-3 CLPPP Initial Report Form
• Lead-4 CLPPP Monthly Report Form
• Lead-5 Onsite Visual Evaluation Form
  

Oral Health

• Fluoride Supplies packing slip-order blank (7-06)
• KIDS SMILES Order form (7-06)
• MSDS -1 Nafrinse Drops
• MSDS-2 Nafrinse Tablets
• MSDS-3 Fluoride Varnish
• MSDS White Varnish Omni
• OH-9 Consent for Fluoride (English and Spanish)
• OH-10 Home Water Sample (1/05)
• OH-10 Spanish (1/05)
• OH-11 Kids' Smiles (personal record)
• OH-11 Spanish
• OH-12 Dental Screening/Exam Form for School Entry
• Prevent Tooth Decay Labels
• Prevent Tooth Decay Labels, Spanish

Prenatal

• ACOG Form A (2003)
• ACOG Form B (2003)
• ACOG Form C (2003)
• ACOG Form D (2003)
• ACOG Form E
• ACOG Form F
• ACOG Form G
• Discharge Postpartum Form
• ACH-282 Prenatal home visit
• ACH-283-A Postpartum Home Visit
• ACH-283-B Postpartum Neonatal Home Visit
• PN-1 consent form screening for cystic fibrosis (Rev. 7/06)
• PN-1 consent form screening for cystic fibrosis, Spanish
• PN-2 Level 1 Substance Use and Pregnancy Questionnaire

Reportable Diseases

• EPID 200: Kentucky Reportable Disease Form

Sexually Transmitted Diseases

• STD-1 Sexual History and Physcial Exam Form (Rev. 7/11)
• STD-1 Instructions

Tobacco

• T-1 Smoking Counseling Sheet

Tuberculosis

• CDC RVCT Form
• TB-1 Infection Form
• TB-2 Contact Investigation
• TB-3 Report of TB Screening
• TB-3 Report of TB Screening, Spanish
• TB-4 TB Risk Assessment Form
• TB-4 Additional Instructions
• TB-5 Candidates for Treatment of Latent Tuberculosis Infection (LTBI)
• TB-CI 1 Contact Investigation Summary
• Sputum Collection Recommendations
• TB H&P-13 TB Clinic Initial Health Assessment/History/Exam (3/12)

General

• ACH-10 Improving Health for Men
• ACH-40 Improving Health for Women
• ACH-40 Spanish
• GPEM-1 Safe Options for Home Needle Disposal
• GPEM-2 Proper Disposal of Prescription Drugs
• Guide to Lowering Blood Pressure
• PAM-ACH-265 Pregnancy Tests (1/10)
• PAM-ACH-265 Pregnancy Tests, Spanish
• Patient Satisfaction Survey
• Patient Satisfaction Survey, Spanish

Domestic Violence

• Service Providers and Contact Information
• Safety Plan Pamphlet

Family Planning

• ACHI-9 Healthier Lifestyles for Family Planning (7/11)
• ACHI-9 Spanish (7/11) 
• ACHI-12 DES Exposure (4/06)
• FPEM-1 Family Planning Methods (Rev. 8/10) 
• FPEM-1 Family Planning Methods, Spanish (Rev. 8/10)
• FPEM-2 Emergency Contraceptive Pills (Rev. 1/10)
• FPEM-2 Emergency Contraceptive Pills,Spanish (rev. 1/10)
• FPEM-3 Abstinence (Rev. 11/07)
• FPEM-3 Abstinence, Spanish (Rev. 11/07)
• FPEM-4 Combined Oral Contraceptive Pills (Rev. 11/07)
• FPEM-4 Combined Oral Contraceptive Pills, Spanish (Rev. 11/07)
• FPEM-5 Progestin-only Pill (Rev. 1/10) 
• FPEM-5 Progestin-only Pill, Spanish (Rev. 1/10)
• FPEM-6 Depo-Provera (Rev. 7/11)
• FPEM-6 Depo-Provera, Spanish (Rev. 7/11)
• FPEM-7 Implanon (11/07)
• FPEM-7 Implanon, Spanish (11/07)
• FPEM-8 Ortho Evra Patch (Rev. 11/07) 
• FPEM-8 Ortho Evra Patch, Spanish (Rev. 11/07)
• FPEM-9 NuvaRing (Rev. 11/07) 
• FPEM-9 NuvaRing, Spanish (Rev. 11/07)
• FPEM-10 Intrauterine Device (Rev. 11/07)
• FPEM-10 Intrauterine Device, Spanish (Rev. 11/07)
• FPEM-11 Female Sterilization (Rev. 11/07)
• FPEM-11 Female Sterilization, Spanish (Rev. 11/07)
• FPEM-12 Male Sterilization (Rev. 11/07)
• FPEM-12 Male Sterilization, Spanish (Rev. 11/07)
• FPEM-13 Natural Family Planning (Rev. 11/07)
• FPEM-13 Natural Family Planning, Spanish (Rev. 11/07)
• FPEM-14 Diaphragms (Rev. 11/07)
• FPEM-14 Diaphragms, Spanish (Rev. 11/07)
• FPEM-15 Male Condoms (Rev. 11/07)
• FPEM-15 Male Condom, Spanish (Rev. 11/07)
• FPEM-16 Female Condom (Rev. 11/07) 
• FPEM-16 Female Condom, Spanish (Rev. 11/07)
• FPEM-17 Spermicidal Cream (Rev. 11/07) 
• FPEM-17 Spermicidal Cream, Spanish (Rev. 11/07) 
• FPEM-18 Cervical Cap (Rev. 11/07)
• FPEM-18 Cervical Cap, Spanish (Rev. 11/07)

HIV

• PAM-ACH 263 What you should know about HIV/AIDS (4/06)
• PAM-ACH 263 What You Should Know About HIV/AIDS (4/06) Spanish

Lead

• ACH-25 What is Lead (Rev. 1/12)
• ACH-25 What is Lead, Spanish (Rev. 3/03)

Oral Health

• OHEM-3 Fluoride Varnish 
• OHEM-4 BrushUp Tips
• OHEM-4 BrushUp Tips, Spanish
• OHEM-5 First Aid for Dental Injury
• OHEM-6 Keeping Your Smile
• OHEM-7 Mouthguard
• OHEM-8 Diabetes and Gum Disease
  

Points to Remember

• ACH-12: Your Newborn to 1 Month Old
• ACH-12: Your Newborn to 1 Month Old, Spanish
• ACH-13: Your Baby 2 to 9 Months
• ACH-13: Your Baby 2 to 9 Months, Spanish
• ACH-14: Your 12 Month Old 
• ACH-14: Your 12 Month Old, Spanish
• ACH-15: Your 15 to 18 Month Old 
• ACH-15: Your 15 to 18 Month Old, Spanish
• ACH-16: Your 2 or 3 Year Old 
• ACH-16: Your 2 or 3 Year Old, Spanish
• ACH-17: Your 4 Year Old 
• ACH-17: Your 4 Year Old, Spanish
• ACH-18: Your 5 or 6 Year Old
• ACH-18: Your 5 or 6 Year Old, Spanish
• ACH-19: Your 8 Year Old 
• ACH-19: Your 8 Year Old, Spanish
• ACH-20: Your 10 Year Old
• ACH-20: Your 10 Year Old, Spanish
• ACH-21: When You Are 11 to 14
• ACH-21: When You Are 11 to 14, Spanish
• ACH-22: When You Are 15 to 17
• ACH-22: When You Are 15 to 17, Spanish
• ACH-23: When You Are 18 to 20
• ACH-23: When You Are 18 to 20, Spanish

Prenatal

• ACHI-11 Safe Sleeping for Baby (11-05)
• ACHI-11S Safe Sleeping for Baby (Spanish)
• KIDS NOW brochure (11-05)
• PAM-ACH-8 Healthier Lifestyles for the Pregnant, Breastfeeding, and Postpartum Woman
• PAM-ACH-8 - Spanish
  

Tobacco

• TEM-1 Coping With Withdrawal Symptoms