Forms and Information Sheets

Commonly Used Forms

Clinic Forms

• Ancillary Test Order Form
• Bed Request Form
• Blue Referral Form
• Clinic Order Form
• Controlled Substance Medication Contract
• Dental School Referral Information
• General Consent Form (English)
• General Consent Form (Spanish)
• Lab Order Form for Direct Phlebotomy
• Morbidity Review Form
• Mortality Review Form
• New Patient Personal Health Summary
• Patient Lab Result Form
• Standard Clinic Referral Form
• Release of Medical Information
• Work excuse

Resident & Student Forms

• Resident Evaluation Form
• Student Evaluation Form

Patient Information & Procedure Sheets

Dietary Information

• 10 ways to cut the fat
• Diet sheet
• Chief sources of dietary fiber
• Potassium sources
• Sodium chart
• Tips for healthy eating
• Vitamin K

Procedures and Preparation Information

• 24 hr Urine instructions
• Colonoscopy Handout
• EGD Handout
• FlexSig Handout
• Go-NuLytely Handout
• Phospho-Soda Handout

Women's Health

• Kegel exercises

Enhanced Care Forms & Information

Diabetes Forms and Information

Patient Forms and Information

• Diabetes Visit Summary
• Plate Method (English)
• Plate Method (Spanish)
• Take Care of Your Diabetes
• Treatment of Hypoglycemia Handout
• Glucose Log, alternating schedule (70-30 BID)
• Glucose Log, fasting & post-supper (Glargine and PM log)
• Glucose Log, fasting AM & alternating PM (long acting and log)
• Glucose Log, fasting only
• Glucose Log, general testing, pre & postprandial
• Glucose Log, premeal AM & PM log (NPH, BID)
• Insulin, Lantus Self Adjustment Diary
• Insulin, Lantus  Treat to Target Schedule (Spanish)
• Insulin, sliding scale 1
• Insulin, sliding scale 2
• Insulin, sliding scale 3
• Insulin, sliding scale 4
• Insulin, sliding scale 5
• Insulin, sliding scale 6

Provider Forms and Information

• ADA Diabetes Class brochure
• ADA Diabetes Class referral fax form
• Diabetes custom fitted shoe Rx
• Diabetes Provider Intervention form
• Glucose monitoring recommendations for providers

Hypertension Forms and Information

• Blood Pressure Log

Tobacco Cessation

Patient Information

• Smoking cessation checklist
• Smoking Cessation Quit Kit
• Smoking cessation reasons & when you quit

Provider Forms

• Smoking cessation protocol
• Commit 2mg Rx1
• Commit 2mg Rx2
• Commit 2mg Rx3
• Commit 4mg Rx1
• Commit 4mg Rx2
• Commit 4mg Rx3
• Inhaler Rx1
• Inhaler Rx2
• Inhaler Rx3
• Nicoderm CQ Rx1
• Nicoderm CQ Rx2
• Nicoderm CQ Rx3
• Nicorette Gum 2mg Rx1
• Nicorette Gum 2mg Rx2
• Nicorette Gum 2mg Rx3
• Nicorette Gum 4mg Rx1
• Nicorette Gum 4mg Rx2
• Nicorette Gum 4mg Rx3
• Nicorette Patch Rx1
• Nicorette Patch Rx2
• Nicorette Patch Rx3

Anticoagulation Information

• Warfarin medication calendar
• Warfarin tablet (generic) identification
• Warfarin tablet (brand) identification
• Home INR Monitoring Waiver Form

Depression Screening

• PHQ9 and Suicidality Form

Domestic Violence Information

• Domestic Violence resources