Women's Health Branch: Forms
To request forms, complete the Clinic Order Form (PDF, 820 KB) - 12/04/20. The forms listed below by program are used for tasks such as ordering resources and recording patient information. If an item doesn’t open properly, please try a different web browser like Internet Explorer, Mozilla Firefox or Google Chrome. If you need a form which is not listed below, please call (919) 707-5700.
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Family Planning - 12/04/20
Clinic Forms
- Family Planning and Reproductive Health Female Flow Sheet (DHHS 2814F) (PDF, 189 KB) - 10/20
- Family Planning and Reproductive Health Male Flow Sheet (DHHS 2814M) (PDF, 179 KB) - 10/20
- Female Reproductive Health History Form (DHHS 4060F) (PDF, 159 KB) - 10/20
- Male Reproductive Health History Form (DHHS 4060M) (PDF, 152 KB) - 10/20
- Pregnancy Testing Form (DHHS 4140) (PDF, 166 KB) - 11/19 (02/05/20)
- Preventing Chickenpox in Pregnant Women: English Version; Spanish Version - For positive pregnancy results, the agency may use this handout or another handout the agency chooses to satisfy the requirement of “Varicella Handout Given/Reviewed” on the "Pregnancy Testing Form".
- Women's Health Clinic Appointment Card (DHHS 1403) (PDF, 199 KB) - 06/18; Clínica de Salud Para La Mujer (DHHS 1403S) (PDF, 215 KB) - 06/18
- Natural Family Planning Chart (DHHS 3059) (PDF, 76 KB) - 05/07; Gráfica Para La Planificación Familiar Natural (DHHS 3059-Spanish) (PDF, 453 KB) - 10/04
Consent Forms
- Abstinence Consent Form (DHHS 4101) (PDF, 118 KB) - 08/16; Solicitud y Consentimiento Para Utilizar el Método de Abstinencia Derelaciones Sexuales (DHHS 4101-S) (PDF, 118 KB) - 08/16
- Barrier Contraceptive Consent Form (DHHS 4102) (PDF, 118 KB) - 08/16; Solicitud y consentimiento para utilizar métodos anticonceptivos de barrera (Condones para hombre o mujer, diafragma) (DHHS 4102-S) (PDF, 118 KB) - 08/16
- Copper IUD Consent Form (DHHS 4103) (PDF, 157 KB) - 05/17; Solicitud y consentimiento para utilizar el dispositivo intrauterine de cobre (DHHS 4103-S) (PDF, 159 KB) - 05/17
- DepoProvera Consent Form (DHHS 4104) (PDF, 120 KB) - 08/16; Solicitud y consentimiento para utilizar Depo Provera® (La inyección anticonceptiva) (DHHS 4104-S) (PDF, 120 KB) - 08/16
- Estrogen Containing Contraceptive Consent Form (DHHS 4105) (PDF, 120 KB) - 08/16; Solicitud y consentimiento para utilizar anticonceptivos que contienen estrógeno (Píldoras anticonceptivas combinadas, el parche anticonceptivo y el anillo vaginal) (DHHS 4105-S) (PDF, 126 KB) - 08/16
- Fertility Consent Form (DHHS 4106) (PDF, 115 KB) - 08/16; Solicitud y consentimiento para utilizar el método anticonceptivo del ritmo de fertilidad (DHHS 4106-S) (PDF, 127 KB) - 08/16
- General Consent for Family Planning Services (DHHS 4112) (PDF, 183 KB) - 08/18; Consentimiento para recibir los servicios de planificación familiar (DHHS 4112-S) (PDF, 193 KB) - 09/18 (Either SPANISH version is acceptable to use: 1) currently posted 9/18 version, and 2) previously posted 8/18 version)
- Nexplanon® Consent Form (DHHS 4107) (PDF, 120 KB) - 08/16; Solicitud y consentimiento para utilizar implantes anticonceptivos subcutáneos (Nexplanon®) (DHHS 4107-S) (PDF, 119 KB) - 08/16
- Levonorgestrel IUD Consent Form (DHHS 4108) (PDF, 151 KB) - 05/17; Solicitud y consentimiento para utilizar el dispositivo anticonceptivo de dosificación intrauterina de Levonorgestrel (DHHS 4108-S) (PDF, 166 KB) - 06/06/17
- Progestin-Only Contraceptive Pill Consent Form (DHHS 4110) (PDF, 117 KB) - 08/16; Solicitud y consentimiento para utilizar el anticonceptivo oral de progestina sola (DHHS 4110-S) (PDF, 117 KB) - 09/16
- Request and Consent for Emergency Contraceptive Pills (DHHS 4109) (PDF, 118 KB) - 10/17; Solicitud y consentimiento para utilizar las pastillas anticonceptivas de emergencia (DHHS 4109-S) (PDF, 117 KB) - 10/17
- Spermicide Consent Form (DHHS 4111) (PDF, 116 KB) - 08/16; Solicitud y consentimiento para utilizar el anticonceptivo espermicida (DHHS 4111-S) (PDF, 116 KB) - 09/16
- Sterilization Consent Form (HHS-687/OMB No. 0937-0166); Consentimiento para la esterilización (HHS-687-1/OMB No. 0937-0166)
Media Review Forms - 03/31/20
- Family Planning Media Review Documentation (DHHS 3491) (PDF, 3.3 MB) - (required to use with annual report) - Updated
- Family Planning Media Review Documentation Fill-In Version (PDF, 3.6 MB) - (fillable version of DHHS 3491 Form above) - Updated
- Consumer Family Planning Media Review (DHHS 3491A) (PDF, 147 KB) - (optional to use with Family Planning clients) - 03/20; Revisión de los Medios de Comunicación para la Planificación Familiar del Consumidor (DHHS 3491A-S) (PDF, 183 KB) - (optional to use with Family Planning clients) - 03/20
Other Forms
Community Engagement Plan, Education and Service Promotion Plan and Quality Improvement Project (CEQ)
- Sample Policy (DOCX, 17 KB)
- Sample Template (DOCX, 30 KB)
- Family Planning Quality Improvement (QI) Cheat Sheet (DOCX, 1.4 MB) 05/01/20
Patient Satisfaction Survey 10/29/20
Maternity Services - 06/30/20
Maternal Health Forms, Checklists, Instructions, Questionnaires, and Definitions
- DHHS 1403 - Women's Health Clinic Appointment Card (PDF, 199 KB) - 06/18; Clínica de Salud Para La Mujer (DHHS 1403S) (PDF, 215 KB) - 06/18
- DHHS 3964 - Maternal Physical Examination (PDF, 270 KB) - 04/20
- DHHS 3966 - Maternal Health Education (PDF, 147 KB) - 04/20
- DHHS 3967 - Maternal Flow (PDF, 219 KB) - 06/20
- DHHS 3968 - Continuation Maternal Flow (PDF, 128 KB) - 05/19
- DHHS 4010 - Maternal Health Laboratory Data (PDF, 174 KB) - 04/20
- DHHS 4095 - Maternal Health Risk Guide (PDF, 153 KB) - 08/18
- DHHS 4115 - Gestational Diabetes Postpartum Testing Checklist (PDF, 142 KB) - 05/19
- DHHS 4116E - Lead and Pregnancy Risk Questionnaire (PDF, 146 KB)
- DHHS 4116S - Lead and Pregnancy Risk Questionnaire / Bilingual (PDF, 196 KB) - 12/18
- DHHS 4151 - Home Visit for Postnatal Assessment and Follow-Up Care (PDF, 227 KB) - 06/20
- DHHS 4152 - Home Visit for Postnatal Assessment and Follow-Up Care Instructions (PDF, 150 KB) - 06/20
- DHHS 4154 - Maternal Health History, Part A (Allergy / Contraceptive / Family / Medical / Menstrual / Obstetrical / Sexual) (PDF, 155 KB) - 09/18
- DHHS 4154 - Historial De Salud Materna, Parte A (Allergia / Anticonceptivos / Famil / Médica / Menstrual / Obstétrico / Sexual) (PDF, 311 KB) - 09/18
- DHHS 4155 - Maternal Health History, Part A Definitions (PDF, 202 KB) - 09/18
- DHHS 4155 - Historial De Salud Materna, Parte A Definiciones (PDF, 359 KB) - 09/18
- DHHS 4156 - Maternal Health History, Part B (Genetic / Teratology / Infection / Immunization) (PDF, 139 KB) - 09/18
- DHHS 4157 - Maternal Health History, Part B Definitions (PDF, 124 KB) - 09/18
- DHHS 4158 - Maternal Health History, Part C-1 (Initial Psychosocial Screening) (PDF, 126 KB) - 09/18
- DHHS 4159 - Historia De Salud De La Madre, Parte C-1 (Evaluación psicosocial inicial) (PDF, 169 KB) - 09/18
- Modified 5Ps (PDF, 84 KB) - 01/20
- Modified 5Ps Spanish (PDF, 87 KB) - 01/20
- PHQ9 (Word, 31 KB)
- PHQ9 Spanish (Word, 28 KB)
- DHHS 4160 - Maternal Health History, Part C-2 (Interval Psychosocial Screening / Results) (PDF, 140 KB)
- DHHS 4161 - Maternal Health History, Part D (Nutrition Screening) (PDF, 122 KB) - 09/18
- DHHS 4162 - Historia De Salud De La Madre, Parte D (Evaluación Inicial Sobre La Nutrición) (PDF, 142 KB) - 09/18
Healthy Beginnings
- Contact and Update Log (DHHS 4145) (PDF, 60 KB)
- Discharge Record (DHHS 4146) (PDF, 63 KB)
- Empowerment Agreement (DHHS 4132) (PDF, 80 KB)
- Postpartum Assessment (DHHS 4142) (PDF, 106 KB)
- Postpartum Service Log (DHHS 4144) (PDF, 83 KB)
- Pregnant Assessment (DHHS 4141) (PDF, 209 KB)
- Pregnant Service Log (DHHS 4143) (PDF, 78 KB)
Baby Love Plus
- NC Baby Love Plus Referral (DHHS 4135) (PDF, 314 KB)
Last Modified: December 4, 2020