California Family Health Council, Inc.

• Adult Health History Questionnaire (PDF)
• Community Outreach Report (Word Doc, 98k)
• Contraceptive Methods Consent Form (Word Doc, 22k)
• Female Medical Exam (PDF)
• Male Health Physical Exam Form (PDF)
• Male Medical Exam (PDF)
• Medical History Update (Word Doc, 108K)
• Patient Reqistration Form (Excel Spreadsheet)
• Title X Chart Audit Form (PDF)
• Women's Health Physical Exam Form (PDF)

Pregnancy Testing and Counseling Forms

All sample forms include basic questions to fcilitate obtaining and documenting appropriate and adequate history and intervention. They vary, however, in the amount of information obtained and protocol guidance given to staff. In addition, one of the forms is designed for client self administration.

• Sample #4 (Word Doc, 33K)

Samples #1, #2, #3, and #5 have been removed. They are being updated and will be reposted.

Sterilization Forms

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)

CFHC invites agencies to make their materials available to others throughout the Title X system. This can be arranged by contacting Barbara Kass-Annese, RNCNP, MSN, Medical Specialist, Clinical & Commmunity Health Programs at 213-386-5614 x4567, email kass-anneseb@cfhc.org.