Women, Infant and Community Wellness Section: Forms

Clinic Forms

• Family Planning and Reproductive Health Female Flow Sheet (DHHS 2814F) (PDF, 138 KB) - 05/06/25
• Family Planning and Reproductive Health Male Flow Sheet (DHHS 2814M) (PDF, 130 KB) - 05/06/25
• Female Reproductive Health History Form (DHHS 4060F) (PDF, 87 KB) - 05/06/25
• Male Reproductive Health History Form (DHHS 4060M) (PDF, 93 KB) - 05/06/25
• Pregnancy Testing Form (DHHS 4140) (PDF, 113 KB) - 05/06/25
  • 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
• Template Patient Demographic Form (DOCX, 30.2 KB) - 07/30/25
• 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

• General Consent for Family Planning Services (DHHS 4112) English and Spanish - 10/25
• Abstinence (DHHS 4101) English and Spanish
• Barrier Method (DHHS 4102) English and Spanish
• Copper IUD (DHHS 4103) English and Spanish
• DepoProvera (DHHS 4104) English and Spanish
• Estrogen Containing Method (DHHS 4105) English and Spanish
• Fertility Awareness Method (DHHS 4106) English and Spanish
• Nexplanon® (DHHS 4107) English and Spanish
• Levonorgestrel Releasing IUD (DHHS 4108) English and Spanish
• Progestin-Only Contraceptive Pill (DHHS 4110) English and Spanish
• Emergency Contraceptive Pills (DHHS 4109) English and Spanish
• Spermicide (DHHS 4111) English and Spanish
• Sterilization English (HHS-687/OMB No. 0937-0166); Large-Print English (HHS-687/OMB No 0937-0166) Sterilization Spanish (HHS-687-1/OMB No. 0937-0166); Large-Print Spanish (HHS-687-1/OMB No. 0937-0166)

Media Review Forms - 03/06/25

• Media Review FAQs (PDF 150KB) - 01/29/25
• Instructions Page Form 3491 and 3491A (PDF 97 KB) - 01/27/25
• Family Planning Media Review Documentation (DHHS 3491) (PDF, 204 KB) 03/06/25
• Consumer Family Planning Media Review (DHHS 3491A) (PDF, 79 KB) 01/27/25
• Consumer Family Planning Media Review Spanish Version (DHHS 3491A) (PDF, 100 KB) 01/27/25

Other Forms - 02/12/24

Public Health Service Sterilization Record (Form PHS-6044) (PDF, 148 KB) 02/12/24

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

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, 139 KB) - 09/22
• DHHS 4151 - Home Visit for Postnatal Assessment and Follow-Up Care (PDF, 192 KB) - 05/24
• DHHS 4152 - Home Visit for Postnatal Assessment and Follow-Up Care Instructions (PDF, 170 KB) - 05/24
• 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, 118 KB) - 06/24 06/25/25
• 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, 121 KB) - 09/23 06/12/24
• DHHS 4159 - Historia De Salud De La Madre, Parte C-1 (Evaluación psicosocial inicial) (PDF, 190 KB) - 09/23
  • 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, 155 KB) 09/23
• 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)