Division of Immigration Health Services DIHS Forms in Word

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Form No.	Title	Price	Buy Now in Word
DIHS 002	Detainee Health Record	$17.50
DIHS 002-cont.	Detainee Health Record (second page)	$17.50
DIHS 075	Pre & Post HIV Test Counseling and Consent Form	$17.50
Standard 522	Request for Administration of Anesthesia and for Performance of Operations and Other Procedures	$17.50
USM 553	Medical Summary of Federal Prisoner/Alien In Transit	$17.50
Standard 600	Progress Notes	$17.50
OMB G-639	Information/Privacy Act	$17.50
DIHS 793	Medical Consent Form	$17.50
DIHS 794	In-Processing Health Screening Form	$17.50
DIHS 795A	Intake Screening Form (has to be typed, 12/07v)	35.00
DIHS 795B	History and Physical Examination Form	$12.99
DIHS 802	Body Diagram Form	$17.50
DIHS TAR	Treatment Authorization Request Form (To be used by detention facility only if/when access to online TARWeb is Unavailable)	$17.50
Account Request Form	Treatment Authorization Web Site (TARWeb) Account Request Form	$17.50
DIHS 819	Detainee Special Needs Form	$17.50
DIHS 820	Refusal Form	$17.50
DIHS 834	Medical /Psychiatric Alert	$17.50
DIHS 835	Suicide Observation Checklist	$17.50
DIHS 836	Input/Output Flow Sheet	$17.50
DIHS 837	SSU Admission and Discharge Form	$17.50
DIHS 837-A	SSU Discharge Summary	$17.50
DIHS 838	Generic Flow Sheet	$17.50
DIHS 839	Hunger Strike Monitoring Form	$17.50
DIHS 840	Health Care Program Medication Profile	$17.50
DIHS 841	Detainee Medical Status	$17.50
DIHS 842	Chronic Disease Flow Sheet - Diabetes	$17.50
DIHS 842-A	Chronic Disease Flow Sheet - Seizure Disorder	$17.50
DIHS 842-B	Chronic Disease Flow Sheet - Tuberculosis	$17.50
DIHS 842-C	Chronic Disease Flow Sheet - Hypertension	$17.50
DIHS 842-D	Chronic Disease Flow Sheet - Asthma	$17.50
DIHS 842-E	Chronic Disease Flow Sheet - HIV/AIDS	$17.50
DIHS 843	Mental Health Screening (revised 10/01)	$17.50
DIHS 843A Creole	Mental Health Screening - Creole	$17.50
DIHS 843B Spanish	Mental Health Screening - Spanish	$17.50
DIHS 844	Consent to use Typical Antipsychotic Medication	$17.50
DIHS 844A-1	Consent to use of Tricyclic Antidepressant Medication	$17.50
DIHS 844B-1	Consent to use Atypical Antipsychotic Medication	$17.50
DIHS 844C-1	Consent to use of Benzodiazepines	$17.50
DIHS 844D-1	Consent to use Lithium	$17.50
DIHS 844E-1	Consent to use of MAOI Antidepressant Medication	$17.50
DIHS 844G-1	Consent to use of Miscellaneous Antidepressant Medication	$17.50
DIHS 844I-1	Consent to use of Serotonin Reuptake Inhibitor Antidepressant Medication	$17.50
DIHS 844J-1	Consent to use of Mood Stabilizing Medication	$17.50
DIHS 844K-1	Consent to use of Buspirone	$17.50
DIHS 845	Juvenile Transfer/Release Summary	$17.50
DIHS 846	Prenatal Care History and Physical Exam Form	$17.50
DIHS 847	Detainee Injury Assessment and Follow-up	$17.50
DIHS 851	Pediatric Physical Assessment Form 2 to 4 weeks	$17.50
DIHS 852	Pediatric Physical Assessment Form 2 months old	$17.50
DIHS 853	Pediatric Physical Assessment Form 4 months old	$17.50
DIHS 854	Pediatric Physical Assessment Form 6 months old	$17.50
DIHS 855	Pediatric Physical Assessment Form 9 months old	$17.50
DIHS 856	Pediatric Physical Assessment Form 12 months old	$17.50
DIHS 857	Pediatric Physical Assessment Form 15 months old	$17.50
DIHS 858	Pediatric Physical Assessment Form 18-23 months	$17.50