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DIHS Forms

Detainee Health Record


DIHS Form 002

Detainee Health Record (second page)


DIHS Form 002-cont.

Pre & Post HIV Test Counseling and Consent Form


DIHS Form 075

Request for Administration of Anesthesia and for Performance of  Operations and Other Procedures


Standard Form 522

Medical Summary of Federal Prisoner/Alien In Transit


USM Form 553

Progress Notes


Standard Form 600

Information/Privacy Act


OMB Form  G-639

Medical Consent Form


DIHS Form 793

In-Processing Health Screening Form


DIHS Form 794

History and Physical Examination Form


DIHS Form 795

Physical Examination Form  -  Continuation


DIHS Form 795 Cont.

Body Diagram Form


DIHS Form  802

Treatment Authorization Request - Consultation (DIHS Internal Use Only) Revised DIHS Form  812
Treatment Authorization Request Form (To be used by detention facility only if/when access to online TARWeb is Unavailable) Revised DIHS Form  TAR
Treatment Authorization Web Site (TARWeb) Account Request Form Account Request Form
MS Word From
PDF Form

Detainee Special Needs Form


DIHS Form 819

Refusal Form


DIHS Form 820

Medical /Psychiatric Alert


DIHS Form 834

Suicide Observation Checklist


DIHS Form 835

Input/Output Flow Sheet


DIHS Form 836

SSU Admission and Discharge Form


DIHS Form 837

SSU Discharge Summary


DIHS Form 837-A

Generic Flow Sheet


DIHS Form 838

Hunger Strike Monitoring Form


DIHS Form 839

Health Care Program Medication Profile  -  or  -  Use CIPS generated form where available


DIHS Form 840

Detainee Medical Status

DIHS Form 841

Chronic Disease Flow Sheet - Diabetes

DIHS Form 842

Chronic Disease Flow Sheet - Seizure Disorder

DIHS Form 842-A

Chronic Disease Flow Sheet - Tuberculosis

DIHS Form 842-B

Chronic Disease Flow Sheet - Hypertension

DIHS Form 842-C

Chronic Disease Flow Sheet - Asthma

DIHS Form 842-D

Chronic Disease Flow Sheet - HIV/AIDS

DIHS Form 842-E

Mental Health Screening   (revised 10/01)

DIHS Form 843

Mental Health Screening  -  Creole

under revision

DIHS Form 843A Creole

Mental Health Screening  -  Spanish

under revision

DIHS Form 843B Spanish

Consent to use Typical Antipsychotic Medication

Revised 5/02

DIHS Form 844

Consent to use of Tricyclic Antidepressant Medication

Revised 5/02 

DIHS Form 844A-1

Consent to use Atypical Antipsychotic Medication

Revised 5/02

DIHS Form 844B-1

Consent to use of Benzodiazepines

Revised 5/02

DIHS Form 844C-1

Consent to use Lithium

Revised 5/02

DIHS Form 844D-1

Consent to use of MAOI Antidepressant Medication

Revised 5/02

DIHS Form 844E-1

Consent to use of Miscellaneous Antidepressant Medication

Revised 5/02

DIHS Form 844G-1

Consent to use of Serotonin Reuptake Inhibitor Antidepressant Medication

Revised 5/02

DIHS Form 844I-1

Consent to use of Mood Stabilizing Medication

Revised 5/02

DIHS Form 844J-1

Consent to use of Buspirone

Revised 5/02

DIHS Form 844K-1

Juvenile Transfer/Release Summary


DIHS Form 845

Prenatal Care History and Physical Exam Form


DIHS Form 846

Detainee Injury Assessment and Follow-up


DIHS Form 847

Pediatric Physical Assessment Form 2 to 4 weeks

DIHS Form 851

Pediatric Physical Assessment Form 2 months old

DIHS Form 852

Pediatric Physical Assessment Form 4 months old

DIHS Form 853

Pediatric Physical Assessment Form 6 months old

DIHS Form 854

Pediatric Physical Assessment Form 9 months old

DIHS Form 855

Pediatric Physical Assessment Form 12 months old

DIHS Form 856

Pediatric Physical Assessment Form 15 months old

DIHS Form 857

Pediatric Physical Assessment Form 18-23 months

DIHS Form 858

Pediatric Physical Assessment Form 2 years old

DIHS Form 859

Pediatric Physical Assessment Form 3 years old

DIHS Form 860

Pediatric Physical Assessment Form 4 years old

DIHS Form 861

Pediatric Physical Assessment Form 5 years old

DIHS Form 862

Pediatric Physical Assessment Form 6 years old

DIHS Form 863

Pediatric Physical Assessment Form 7 years old

DIHS Form 864

Pediatric Physical Assessment Form 8 years old

DIHS Form 865

Pediatric Physical Assessment Form 10 years old

DIHS Form 866

Post-Restraints Observation Report

DIHS Form  867

Chronic Disease Flow Sheet - Mental Health

DIHS Form 868

Medical Observation of Detainee in Restraints

DIHS Form  869

LTBI Treatment Monthly Side Effect - Appendix 2


DIHS Form 882Pending

LTBI in Spanish


DIHS Form 883Pending

LTBI Treatment  -  Appendix 1


DIHS Form 884Pending

UB-92 Medicare Uniform Institutional Provider Bill


CMS Form 1450

Health Insurance Claim Form


CMS Form 1500

Report of Root Cause Analysis Direct any Questions on filling out this form to the DIHS PPE Branch


RCA Form

Dental Examination Form SF 603
Dental Clinical Record Form SF 521
Dental Treatment Continuation Form Form
Dental Screening Form   English
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