Women, Infant and Community Wellness Section: Forms

Clinic Forms

• Family Planning and Reproductive Health Female Flow Sheet (DHHS 2814F) (PDF, 191 KB) - 07/22
• Family Planning and Reproductive Health Male Flow Sheet (DHHS 2814M) (PDF, 198 KB) - 07/22
• Female Reproductive Health History Form (DHHS 4060F) (PDF, 160 KB) - 07/22
• Male Reproductive Health History Form (DHHS 4060M) (PDF, 152 KB) - 07/22
• Pregnancy Testing Form (DHHS 4140) (PDF, 129 KB) - 07/22
  • 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". 02/02/20
• 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

Consent Forms - 05/22/23

• 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, 60 KB) - 05/23; 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, 47 KB) - 05/23; 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); Large-Print English (HHS-687/OMB No. 0937-0166) 07/27/22
  Spanish (HHS-687-1/OMB No. 0937-0166); Large-Print Spanish (HHS-687-1/OMB No. 0937-0166) 07/27/22

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 - 06/23/22

Public Health Service Sterilization Record (Form PHS-6044) (PDF, 122 KB) 10/12/21

Community Engagement Plan, Education and Service Promotion Plan and Quality Improvement Project (CEQ) - 09/28/22

• Sample Policy (DOCX, 17 KB)
• Sample Template (DOCX, 30 KB)
• Family Planning Quality Improvement (QI) Cheat Sheet (DOCX, 1.4 MB)

For further information, visit https://wicws.dph.ncdhhs.gov/provpart/training.htm, click:

• Family Planning Non-Required Trainings section
• Community Engagement Education Awareness Plan and Quality Improvement Project (CEQ) Webinar Series

Patient Satisfaction Survey 10/29/20

• WORD (DOCX, 44 KB); PDF (PDF, 111 KB)
• Spanish - WORD (DOCX, 45 KB); PDF (PDF, 150 KB) 10/29/20

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, 131 KB) - 09/22
• DHHS 3966 - Maternal Health Education (PDF, 153 KB) - 09/22
• DHHS 3967 - Maternal Flow (PDF, 157 KB) - 09/22
• DHHS 3968 - Continuation Maternal Flow (PDF, 104 KB) - 09/22
• DHHS 4010 - Maternal Health Laboratory Data (PDF, 142 KB) - 09/22
• DHHS 4095 - Maternal Health Risk Guide (PDF, 123 KB) - 09/22
• DHHS 4115 - Gestational Diabetes Postpartum Testing Checklist (PDF, 117 KB) - 09/22
• DHHS 4116E - Lead and Pregnancy Risk Questionnaire (PDF, 154 KB) - 09/22
• DHHS 4116S - Lead and Pregnancy Risk Questionnaire / Bilingual (PDF, 142 KB) - 09/22
• DHHS 4151 - Home Visit for Postnatal Assessment and Follow-Up Care (PDF, 192 KB) - 10/22
• DHHS 4152 - Home Visit for Postnatal Assessment and Follow-Up Care Instructions (PDF, 168 KB) - 10/22
• DHHS 4154 - Maternal Health History, Part A (Allergy / Contraceptive / Family / Medical / Menstrual / Obstetrical / Sexual) (PDF, 147 KB) - - 09/22
• DHHS 4154 - Historial De Salud Materna, Parte A (Allergia / Anticonceptivos / Famil / Médica / Menstrual / Obstétrico / Sexual) (PDF, 154 KB) - 09/22
• DHHS 4155 - Maternal Health History, Part A Definitions (PDF, 126 KB) - 09/22
• DHHS 4155 - Historial De Salud Materna, Parte A Definiciones (PDF, 154 KB) - 09/22
• DHHS 4156 - Maternal Health History, Part B (Genetic / Teratology / Infection / Immunization) (PDF, 119 KB) - 09/22
• 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, 120 KB) - 09/22
• DHHS 4159 - Historia De Salud De La Madre, Parte C-1 (Evaluación psicosocial inicial) (PDF, 133 KB) - 09/22
  • Modified 5Ps Spanish (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, 154 KB) 09/22
• DHHS 4161 - Maternal Health History, Part D (Nutrition Screening) (PDF, 81 KB) - 09/22
• DHHS 4162 - Historia De Salud De La Madre, Parte D (Evaluación Inicial Sobre La Nutrición) (PDF, 372 KB) - 09/22

• Contact and Update Log (DHHS 4145) (PDF, 111 KB)
• Discharge Record (DHHS 4146) (PDF, 140 KB)
• Empowerment Agreement (DHHS 4132) (PDF, 154 KB)
• Postpartum Assessment (DHHS 4142) (PDF, 231 KB)
• Postpartum Service Log (DHHS 4144) (PDF, 231 KB)
• Pregnant Assessment (DHHS 4141) (PDF, 212 KB)
• Pregnant Service Log (DHHS 4143) (PDF, 157 KB)

• NC Baby Love Plus Referral (DHHS 4135) (PDF, 314 KB)