Public Health Nursing - Publications and Forms

Forms

• Health Care Record: Client/Household Information (CORE-1) English (pdf, 301K)
• Health Care Record: Client/Household Information Update (CORE-1a) English (pdf, 146K)
• Health Care Record: Physical Exam (CORE-2) English (pdf, 321K)
• Health Care Record: Referral List (CORE-3) English (pdf, 425K) 
• Health Care Record: Medical/Social History (CORE-4) English (pdf, 660K)
• Health Care Record: Medical/Social History (CORE-4) Spanish (pdf, 398K)
• Diet History (CORE-4a) English (pdf, 461K)
• Diet History (CORE-4a) Spanish (pdf, 99K)
• Health Care Record: Flow Sheet Immunizations (CORE-5) English (pdf, 641K)
• Health Care Record: Medication Issued (CORE-6) English (pdf, 218K)
• Health Care Record: Progress Notes (CORE-7) English (pdf, 196K)
• Health Care Record: Triage Note (CORE-8) English (pdf, 153K)
• Authorization to Release Confidential Information/Instructions for Obtaining Consent to Release Medical Information (L-30/L-30a) English (pdf, 182K)
• Authorization to Release Confidential Information/Instructions for Obtaining Consent to Release Medical Information (L-30/L-30a) Spanish (pdf, 329K)
• General Consent and Disclosure (L-36) English and Spanish (pdf, 228K) 
• General Consent/Permission for Provision of Service and Patient Record Form (L-37) (pdf, 17K)
• Referral Form / Instructions (L-29 & L-29a) (pdf,18 kb)
• Statement of Services (L-39) (pdf, 276K)
• STD History and Physical Assessment (pdf, 761K)
• DSHS STD Disclosure Consent Treatment Oral or Injection revised (English) (pdf, 235 kb)
• DSHS STD Disclosure Consent Treatment Oral or Injection revised (Spanish) (pdf, 246 kb)