Title X Family Planning

Enrollment

New client enrollment

Initial health history assessment
District 3-5 Title X Family Planning Clinic will have an “Initial Female or Male Patient History Medical Record” form completed for each client enrolling in the family planning program. To ensure accurate written history assessments on each 1st time enrollee, please follow these steps:

1. Each patient/guardian is asked to complete the Initial Female Patient History Medical Record or Initial Male Patient History Medical Record Form at the first visit.
2. The form is a self-administered questionnaire for the client to complete.
3. The form is available in both English and Spanish:
   • FP 004-A: Initial Female Patient History Form
   • FP 005-A: Initial Male Patient History Form
4. Assistance will be provided as needed by the Registration Clerk or any available family planning staff.
5. The form is placed on the patient’s medical record

A new client enrolling in the family planning program for the first time must complete one of the following “Initial Visit History” forms, and an income declaration form:

• Female Clients – FP 004-A: Initial Female Patient History Form (English)
• Female Clients – FP 004-B: Initial Female Patient History Form (Spanish/English)
• Male Clients – FP 005-A: Initial Male Patient History Form (English)
• Male Clients – FP 005-B: Initial Male Patient History Form (Spanish/English)

Title X Family Planning Registration Forms:

• Family Planning Title X Patient Information and Income Declaration (English)
• Family Planning Title X Patient Information and Income Declaration (Spanish/English)

Return visit forms:

Established – A client returning for family planning service 15 months or longer from the last scheduled visit.
Complete one of the following “Annual Visit History” forms:

• Female Clients – FP 006-A: Annual Female Patient History Form (English)
• Female Clients – FP 006-B: Annual Female Patient History Form (Spanish/English)

Revisit/Established/Problem – An active client returning for service (fewer than 15 months or longer from the last scheduled visit.
Complete one of the following “Interim Visit History” forms:

• Female Clients – FP 007-A: Interim Female Patient History Form (English)
• Female Clients – FP 007-B: Interim Female Patient History Form (Spanish/English)

Note: In addition to the above form, if you are returning for a supply of “Oral Contraceptive (Pills), complete the following questionnaire:

• Checklist for Oral Contraceptive (PILLS) – (English)
• Checklist for Oral Contraceptive (PILLS) – (Spanish/English)

Note: In addition, if you are returning for a “Contraceptive Injection (Shot)”, complete the following questionnaire:

• Checklist for Contraceptive Injection (SHOT) – (English)
• Checklist for Contraceptive Injection (SHOT) – (Spanish/English)