Clinic forms (in alphabetical order) These printed forms can be found at the nurses stations on both sides of clinic and in the preceptor room. Click on the blue hyperlink to access and print.
Advance Directives (English) ACP English
(Spanish) ACP Spanish
AMA form AMA
Blood Pressure Logs (blank)
Blood Sugar logs (blank
Consent forms for procedures Consent Form
Food Logs for patients 7 Day Food Log
FL2 (for skilled nursing and other non-hospital nursing settings) FL2
Interpreter Waiver Form Intepreter Waiver
Maestrocare Downtime Form
NC Care 360 Consent Forms NC Care360
NC DMV Handicap Forms NC DMV Handcap
NC DMV Medical Review Form NC DMV Medical Review
Nutrition- Medicaid payment for Ensure or Boost Medicaid Ensure and Boost
Nutrition- referral to Durham County Public Health Department
Oxygen Saturation Form
PCS Forms for Medicaid and Managed Care
PCS Patient Information Form PCS Info for Patients
Records Release from Duke Health Release from Duke
Records release to Duke Health Release to Duke
Records verbal release to allow family or others to receive communication Release of Records Verbal
Sleep Log for Patients 7 Day Sleep Log
Stool Collection Forms
Transportation Access within Durham (for disabled people to ride para-transit)
Urine collection 24 hour
Obesity Medicine Handouts
Keto Medicine Diet
Moderate Sugar_Starch Eating Plan Handout-DFC-2021-06-21
No Sugar, No Starch Eating Plan Handout-DLWMC-2022-04-04
Mental Health Forms
Adult ADHD Questionnaire Adult ADHD Symptom Checklist
Anxiety GAD7 Anxiety GAD-7 (English)
Bipolar MDQ Screener Mania MDQ
Depression PHQ9 PHQ-9 (English)
Involuntary Commitment (IVC) for psychiatric emergency
Panic Screener Panic Disorder PADIS
