DHHS: DPH: WHB: Forms

To request forms, complete the Clinic Order Form (PDF, 160 KB) - 06/30/19. 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 - 02/26/19

Clinic Forms

As of March 3, 2015, some FP forms are no longer stored at the DPH warehouse and are not listed on the “Clinic Order Form” link listed above (in the first paragraph). Please download the forms you need from the lists below.

Family Planning and Reproductive Health Female Flow Sheet (DHHS 2814F) (PDF, 181 KB) - 01/19
Family Planning and Reproductive Health Male Flow Sheet (DHHS 2814M) (PDF, 164 KB) - 01/19
Female Reproductive Health History Form (DHHS 4060F) (PDF, 142 KB) - 05/17
Male Reproductive Health History Form (DHHS 4060M) (PDF, 125 KB) - 05/17
Frequently Asked Questions on Revised Family Planning Clinic Forms (PDF, 294 KB) - 08/17
Pregnancy Testing Form (DHHS 4140) (PDF, 92 KB) - 05/17
- 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 - 02/26/19

Family Planning Media Review Documentation (DHHS 3491) (PDF, 1.4 MB) - (required to use with annual report) - 02/19
Family Planning Media Review Documentation Word Fill-In Version (Word, 143 KB) - (electronic version of DHHS 3491 Form above) - 02/19
Consumer Family Planning Media Review (DHHS 3491A) (PDF, 125 KB) - (optional to use with Family Planning clients) - 06/16; Revisión de los Medios de Comunicación para la Planiﬁcación Familiar del Consumidor (DHHS 3491A-S) (PDF, 94 KB) - (optional to use with Family Planning clients) - 09/16

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)

Maternity Services - 06/30/19

Maternal Health Forms, Checklists, Instructions, Questionnaires, and Definitions

DHHS 1403 - Women's Health Clinic Appointment Card (PDF, 199 KB)
DHHS 1403S - Clínica de Salud Para La Mujer (PDF, 215 KB)
DHHS 3964 - Maternal Physical Examination (PDF, 255 KB) - 08/18
DHHS 3966 - Maternal Health Education (PDF, 141 KB) - 05/19
DHHS 3967 - Maternal Flow (PDF, 190 KB) - 05/19
DHHS 3968 - Continuation Maternal Flow (PDF, 128 KB) - 05/19
DHHS 4010 - Maternal Health Laboratory Data (PDF, 152 KB) - 05/19
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, 146 KB)
DHHS 4151 - Home Visit for Postnatal Assessment and Follow-Up Care (PDF, 222 KB) - 06/19
DHHS 4152 - Home Visit for Postnatal Assessment and Follow-Up Care Instructions (PDF, 132 KB) - 05/19
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, 68 KB)
- Modified 5Ps Spanish (PDF, 69 KB)
- 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: July 9, 2019

Women's Health Branch: Forms