MEDICAL FORMS
A

Last Updated: 29 October 2004

A

• A Soldier's Guide to Staying Healthy at High Elevations - This product is printed black and white as a 6-page accordion folded booklet on waterproof or coated paper. The finished product is 11 ¼"" x 8 ½" folded to 3 ½" x 8 ½". This booklet contains health threat and countermeasure information from the most current data available from U.S. Department of Defense Medical Agencies at the time of production. Topics within the booklet include: Overview; Elevation Measurements; Medical Terms (i.e., HAPE, HACE); The Human Body's Response to High Altitude; Acclimatization; High Altitude Illnesses; Environmental Threats; and High Mountain Operations. Department of the Army [PDF 166KB]
• Abbreviated Medical Record
• Abdominal Pain - Discharge Instructions
• Abdominal Pain - Discharge Instructions
• Abdominal Pain - Discharge Instructions
• Abdominal Pain - Emergency Department Patient Discharge Instructions
• Abdominal Pain - Physician's Order Sheet [PDF 16Kb]
• Abdominal Pain (Child) - Discharge Instructions
• Abdominal Pain Form - Emergency Department - Chief Complaint Forms
• Abdominal Pain Form - Physician's Office - Chief Complaint Forms
• Abdominal Pain, Sample Observation Unit Protocol
• Abnormal Uterine Bleeding - Patient Handout
• Abrasions - Discharge Instructions
• Abscess - Discharge Instructions
• Abscesses - Discharge Instructions
• Acne - Patient Handout
• Act in Time to Heart Attack Signs Physician Quick Reference Card - This handy card give physicians and other health care providers talking points for discussing heart attack warning signs and survival steps with patients. It outlines the T.I.M.E. method for helping patients understand and feel comfortable with the advice being given. The reference card also includes suggested responses to common patient concerns, including questions about heart attack treatments, embarrassment about calling 9-1-1 for a false alarm, and worry about upsetting family members. Printed on sturdy, glossy paper, 8 1/2 x 11 inches. NIH Publication No. 01-3313 [PDF 228kb]
• Act in Time to Heart Attack Signs Wallet Card - This pocket-sized card for wallet or purse gives brief reminders of heart attack warning signs, steps to take if symptoms occur, and the importance of acting quickly. Offers space to write in current medications and key phone numbers as an easy reference for both the patient and emergency care providers. This colorful, tri-fold card fits is 2 1/8 by 3 1/4 inches. Great for health fairs, information centers, and health care providers too. NIH Publication No. 01-3667 [PDF 140Kb]
• Acute Bronchitis - Patient Handout
• Acute Myocardial Infarction Management Pocket Guide - Pharmacological Therapy
• Acute Myocardial Infarction, Suspected Pocket Guide
• ADHD in Adults - Patient Handout
• ADHD in Children - Patient Handout
• ADHD Medicines - Patient Handout
• ADHD: Does My Child Have It? - Patient Handout
• ADHD: Info and Advice for Parents - Patient Handout
• Administrative Forms - Age Specific Competency Assessment Form
• Administrative Forms - Annual Competency Assessment: Patient Care Technician, Critical Care Services
• Administrative Forms - Annual Competency Assessment: RN Maternity/L&D
• Administrative Forms - Annual Competency Assessment: RN Medical Surgical
• Administrative Forms - Annual Competency Assessment: RN Nursery
• Administrative Forms - Competency Check List
• Administrative Forms - Department Orientation Check List
• Administrative Forms - Employee Immunization Authorization
• Administrative Forms - EMS Preceptor Evaluation Sheet
• Administrative Forms - Exit Interview for Registered Nurses
• Administrative Forms - Hepatitis B Immunity Statement/Completion Form
• Administrative Forms - Incident Report
• Administrative Forms - Incident Report
• Administrative Forms - Incident Report
• Administrative Forms - Job Description/Performance Appraisal, Administrative Supervisor
• Administrative Forms - Job Description/Performance Appraisal, Director-Critical Care
• Administrative Forms - Job Description/Performance Appraisal, Registered Nurse - Critical Care
• Administrative Forms - Job Description/Performance Appraisal, Registered Nurse, Maternity/L&D
• Administrative Forms - Job Description/Performance Appraisal, Registered Nurse - Nursery
• Administrative Forms - Job Description/Performance Appraisal, RN, Medical Surgical Services
• Administrative Forms - Medical Report of Duty Status
• Administrative Forms - Medical Staff Census Worksheet
• Administrative Forms - Medication Competencies
• Administrative Forms - Nurses Work Schedule
• Administrative Forms - Nursing Unit 24 Hour Report
• Administrative Forms - Nursing Unit 24 Hour Report Continuation Sheet
• Administrative Forms - OR Nurse Orientation, Pathway Format
• Administrative Forms - Professional Career Questionnaire, Nurses
• Administrative Forms - Quarterly Performance Review Report
• Administrative Forms - Registered Nurse (RN) Competency/Skills Assessment Orientation Checklist
• Administrative Forms - Registered Nurse (RN), Medical Surgical Services, Orientation/Competency Inventory
• Administrative Forms - Staff Education: Group Record
• Administrative Forms - Staff Education: Individual Record
• Admission Bed Slip
• Admission Orders - Adult Inpatient Psychiatry Forms
• Admission Orders - Child Inpatient Psychiatry Forms
• Admission Request Adult - Emergency Department Psychiatry Forms
• Admission Request Child - Emergency Department Psychiatry Forms
• Admitting Note & Pre-Surgical Orders - NY Eye and Ear [PDF 98kb]
• Admitting Orders - Emergency Physician [PDF 15Kb]
• Adult Admission Involuntary - Emergency Department Psychiatry Forms
• Adult Admission Voluntary - Emergency Department Psychiatry Forms
• Adult History and Goals Questionnaire
• Adult Medical History Form
• Advance Directive Policy and Form
• Advance Directives Worksheet
• Advanced Directive
• Advanced Directive Form
• Adverse Effects of Cold - Pocket card, 2.5" x 3.5", Black and White. Printed on both sides. Side one of the card lists two types of cold injuries: Freezing Injury ( frostbite) and Nonfreezing ("trench foot", "immersion foot"). Cause and Symptoms are provided for each. Side two explains how to prevent from being cold and first-aid treatment. Department of the Army
• Against Medical Advice Release Form, AMA - EMS Provider [PDF]
• Against Medical Advice Form, AMA - Refusal to follow medical advice regarding consent to the emergency treatment, transfer or discharge form. [PDF]
• Age Specific Competency Assessment Form
• AIMS - Psychiatry Forms Ratings Scales and Questionnaires
• Air Pollution, Indoor - Patient Handout
• Airway Management Documentation Form - Charlottesville Albemarle Rescue Squad [PDF 2pp. 94Kb]
• Airway Obstruction Sheet - Educational Handout
• Alcohol or Drug Abuse Recovery: Your Doctor Can Help - Patient Handout
• Alcohol Withdrawal Syndrome - Patient Handout
• Alcohol: What to Do If It's a Problem for You - Patient Handout
• Allergies - Discharge Instructions
• Allergy Diet - Patient Handout
• Allergy Treatment - Medical Record
• Ambulance Checklist - Charlottesville Albemarle Rescue Squad [PDF 1pp. 72Kb]
• Ambulance Decontamination Checklist - Charlottesville Albemarle Rescue Squad [PDF 1pp. 9Kb]
• Ambulatory/Outpatient Care Medication Flow Sheet
• AMI Pullout Card - Management of Acute Myocardial Infarction
• Anatomical Gift Form
• Anesthesia Case Review Data Collection Sheet
• Angina - Discharge Instructions
• Angina - Patient Information
• Angina - Patient Information Sheet
• Angiogram - Patient Discharge Instructions
• Animal Bite - Discharge Instructions
• Ankle Sprain - Discharge Instructions
• Ankle Sprain - Discharge Instructions
• Annual Competency Assessment - Patient Care Technician, Critical Care Services
• Annual Competency Assessment - RN Maternity/L&D
• Annual Competency Assessment - RN Medical Surgical
• Annual Competency Assessment - RN Nursery
• Anorexia - Patient Handout
• Antibiotic Resistance - Patient Handout
• Anticoagulant and Antiplatelet Agents - Patient Information Sheet
• Anti-Inflammatory Drugs - Patient Handout
• Anti-Inflammatory Medications - Medication Instructions
• Appendicitis - Patient Handout
• Appointment Cards
• Arizona Health Care Power of Attorney
• Arizona Prehospital Medical Care Directive
• Arrest Pocket Card - CPMC Medical House Staff Arrest Card. New York Presbyterian Hospital, Columbia Presbyterian Medical Center [PDF 2pp. 216Kb]
• Arrhythmia - Patient Information Sheet
• Artificial Respiration/Basic Cardiac Life Support: Pocket Card - This 3"x4.5" trifold opens to 6 panels and is to be used in conjunction with FM 21-11. It depicts procedures for aiding victims who are choking or those victims who are having a heart attack. It is divided into 2 parts. Part A is Airway and Respiration and Part B is CPR. Each part gives step by step details on how to perform the procedure. Department of the Army
• Asthma - Discharge Instructions
• Asthma - Discharge Instructions
• Asthma - Discharge Instructions (Child)
• Asthma - Physician's Order Sheet [PDF 16Kb]
• Asthma - Protocol, Criteria and order sheet
• Asthma / Allergy Action Card -  Information your child care provider needs to care for your young child who has asthma and allergies.  Complete the information for your child's medication plan, their specific signs and symptoms that say your child is having trouble breathing, and the steps that need to be taken in an emergency situation.
• Asthma Action Card - Tool for communicating your school age (5-18) child's asthma management plan to school personnel.  Have your child's asthma triggers, daily medication and emergency directions on file at their school, after school and extra curricula locations, camps and community centers.
• Asthma Action Plan - Patient Handout
• Asthma and Your Child - Patient Handout
• Asthma Flare-ups - Patient Handout
• Asthma Guidelines - Pocket Card
• Asthma Management
• Asthma Management and Prevention in Children Pocket Guide - Summary of patient care information for pediatricians and other health care professionals. NIH Publication
• Asthma Management and Prevention Pocket Guide - Summary of patient care information for primary health care professionals. NIH Publication
• Asthma Medications - Patient Handout
• Asthma: Controller and Quick-Relief Medicine - Patient Handout
• Asthma: Learning to Control Your Symptoms - Patient Handout
• Asthma: Questions to Ask When It Doesn't Get Better - Patient Handout
• Asthma: Taking Medicines Safely - Patient Handout
• Atrial Fibrillation - Patient Information Sheet
• Attention-deficit hyperactivity disorder - Patient Handout
• Authorization for Emergency Care to Minor (s)
• Authorization for Emergency Care to Minor (s)
• Authorization for Medication to be Taken at School (Word Format)
• Authorization for Release of Information from Medical Record
• Authorization for Release of Medical Information
• Authorization for Release of Minor and/or Minor's Records to Person Other Than Parent or Guardian
• Authorization for Treatment to Minor (s)
• Authorization to Consent to Treatment of Minor  (Word Format)
• Authorization to Consent to Treatment of Unemancipated Minor Form
• Authorization to Release Health Care Information
• Authorization to Release Health Care Information (online)
• Auto Emergency Kit Checklist
• Automated External Defibrillator (AED) - Maintenance Checklist
• Automated External Defibrillator (AED) - Sample Policy
• Automated External Defibrillator (AED) - Sample School Policy
• Automated External Defibrillator (AED) - Sample School Procedure
• Avoiding Giardiasis - Patient Handout

next   contents