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Patient History Forms

• Adult Health History Questionnaire - PDF | Word
• Medical History Update - Word
• Medical Male Initial History
  • In English - PDF | Word
  • In Spanish - PDF | Word
• Medical History Forms for Females and Males
  • From the FamilyPACT website
• STD Risk Assessment Questionnaire - PDF | Word

Physical Exam Forms

• Female Health Physical Exam Form - PDF
• Female Medical Exam - PDF | Word
• Male Health Physical Exam Form - PDF | Excel
• Male Medical Exam 1 - PDF | Word
• Male Medical Exam 2 - PDF | Word
• Medical Exam Forms for Females and Males
  • From the FamilyPACT website

Contraception Visit Forms

• Contraceptive Methods Consent Form PDF - | Word
• Medical Consent for Family Planning Services
  • In English - PDF | Word
  • Spanish - PDF | Word
  • Method Specific Contraception Consent in English & Spanish
    PDF | Word
• Sterilization Consent Form (Family PACT Patients)
  Note: Effective February 1, 2006, Family PACT uses the Federal Sterilization consent form (PM 330), the same consent form used by the Medi-Cal program. This form can only be ordered (free of charge) through the Department of Health Services Central Warehouse Facility by calling 916-928-9203. 
  • Instructions for ordering and completing the form (Word Document, Medi-Cal website)
  • Tutorial on counseling clients and completing the PM 330 form (Family PACT website)
    • To facilitate reimbursement, please read carefully.
• Sterilization Consent Form (Private Pay / Non-Family PACT Patients)
  Should you choose to use your Title X funds to support sterilization services, you must use the OMB federal sterilization consent forms. Forms are available online from the HHS website. Scroll down the page for PDF or Microsoft Word format.
  • HHS-687 English (HHS website)
  • HHS-687-1 Spanish (HHS website)

Pregnancy Testing & Counseling

• Pregnancy Counseling Flow Form PDF | Word
• Pregnancy Testing (Preconception) Form PDF | Word

Want to help out?

CFHC invites agencies to make their materials available to others throughout the Title X system. This can be arranged by contacting Dannelle Pietersz, NP, MSN, MPH, Medical Specialist, Clinical & Community Health Programs at 213-386-5614 x4546, email pieterszd@cfhc.org.