Clinical Forms Catalogue

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Due to the large list of forms below, using the CTRL+F (Find) function will generate a search bar at the top right corner of the screen where you can begin typing key words. Where there are multiple documents with the same key word(s), use the arrows in the search box to view each document.

  • Provincial and Former Health Region Forms Catalogue

    • The above catalogue includes former health region forms as well as a link to this provincial catalogue. It does not include all of the former region forms, as they are still in the process of being gathered.

  • Document Finder Forms

    • The above link includes all forms in Document Finder (clinical and non-clinical).

  • Printing Services

    • Includes information to printing services across the province as well as links to forms catalogues. 

A

Acetylcysteine SMART Pump Checklist - 100 kg and Over (SHA 0248)
(PDF 456.43 KB)
Published January 10, 2023
Acetylcysteine SMART Pump Checklist - Under 100 kg (SHA 0247)
(PDF 453.47 KB)
Published January 19, 2023
Acquired Brain Injury Program - Progress Notes (SHA 0204)
(PDF 190.73 KB)
Published May 9, 2022
Acquired Brain Injury Program Referral Form (SHA 0222)
(PDF 212.71 KB)
Published May 6, 2022
Acute Agitation Monitoring Record (SHA 0274)
(PDF 470.31 KB)
Published June 2, 2023
Advance Care Planning Documentation Record (SHA 0325)
(PDF 444.26 KB)
Published August 30, 2023
ALS/MND Clinic - Spirometry Report (SHA 0500)
(PDF 123.05 KB)
Published November 19, 2024
Anaphylaxis Treatment Worksheet (SHA 0232)
(PDF 495.08 KB)
Published September 12, 2022
Animal Exposure - LETTER - 10 Day Low Risk (SHA 0275)
(PDF 749.42 KB)
Published August 25, 2023
Animal Exposure - LETTER - Owner Contact (SHA 0276)
(PDF 763.71 KB)
Published August 25, 2023
Animal Exposure - LETTER - Victim as Owner (SHA 0277)
(PDF 741 KB)
Published August 25, 2023
Animal Exposure - LETTER - Victim Contact (SHA 0280)
(PDF 739.97 KB)
Published August 25, 2023
Animal Exposure - Report Form (SHA 0281)
(PDF 554.68 KB)
Published May 29, 2023
Appointing a Proxy - Form - Advance Care Planning (SHA 0326)
(PDF 681.53 KB)
Published September 29, 2023

B

Baby Friendly Initiative - Implementation Checklist (SHA 0385)
(DOCX 90.96 KB)
Published January 10, 2024
Bariatric Surgical Program Patient Referral Form (SHA 0273)
(PDF 463.88 KB)
Published May 23, 2023
Breastfeeding/Chestfeeding Assessment Tool (SHA 0345)
(PDF 737.94 KB)
Published December 14, 2023

C

Clinical Nurse Specialist Notes - Stroke (SHA 0380)
(PDF 463.92 KB)
Published November 4, 2024
Clinical Summary - Kidney Stone Prevention Clinic (KSPC) (SHA 0443)
(PDF 119.49 KB)
Published October 17, 2024
Confidential Health Matter Letter - Public Health (SHA 0314)
(PDF 739.49 KB)
Published January 8, 2024
Consent for Disclosure of Medical Images (SHA 0144)
(PDF 311.93 KB)
Published September 14, 2021
COPD Home Health Monitoring (HHM) Referral Form (SHA 0435)
(PDF 168.03 KB)
Published November 20, 2024
Cough Assist Record of Care (SHA 0143)
(PDF 237.67 KB)
Published August 18, 2021
Cough Assist Transfer Checklist (SHA 0142)
(PDF 226.13 KB)
Published July 15, 2021
COWS – Clinical Opioid Withdrawal Scale (SHA 0058)
(PDF 562.96 KB)
Published August 23, 2023

D

Death Determination by Neurologic Criteria Checklist (SHA 0332)
(PDF 706.57 KB)
Published October 3, 2023
Diabetes Monitoring - Take Home Sheet - PEDIATRIC (SHA 0286)
(PDF 457.26 KB)
Published January 25, 2024
Dietitian Referral Form - Continuing Care (SHA 0206)
(PDF 210.03 KB)
Published March 7, 2022
Discharge Instructions for Baby - HIV Prevention (SHA 0151)
(PDF 350.48 KB)
Published May 2, 2022
Discharge Summary Sheet - Kidney Health Clinic (SHA 0391)
(PDF 463.92 KB)
Published January 31, 2024

E - F

Ear Irrigation - ADULT - Skills Checklist (SHA 0395)
(PDF 526.53 KB)
Published March 5, 2024
Early Pregnancy Assessment Clinic - Discharge Summary (SHA 0378)
(PDF 448.27 KB)
Published November 1, 2024
Echocardiogram Requisition - PEDIATRIC (SHA 0340)
(PDF 137.78 KB)
Published November 15, 2024
EMS and Community Paramedicine Referral Form (SHA 0203)
(PDF 426.67 KB)
Published February 18, 2022
Falling Star Icon Stickers - Avery 22805 Labels (SHA 0367)
(PDF 79.91 KB)
Published November 29, 2023
Falls Tracking Tool - Long Term Care (SHA 0364)
(PDF 477.01 KB)
Published November 22, 2023
Forensic Evidence Record - SANE (SHA 0350)
(PDF 504.27 KB)
Published October 31, 2024
Frostbite Injury Monitoring - Practitioner (SHA 0238)
(PDF 549.14 KB)
Published November 8, 2022
Functional Neurosurgery for Pain Referral - REGINA (SHA 0478)
(PDF 481.45 KB)
Published October 28, 2024

G - H

General Anxiety Disorder - GAD-7 (SHA 0251)
(PDF 440.11 KB)
Published January 18, 2023
HIV PEP Kit Replacement Form (SHA 0315)
(PDF 714.56 KB)
Published February 1, 2024
Human Factors Analysis for Patient Safety Incidents (SHA 0461)
(PDF 542.85 KB)
Published September 26, 2024
Hyperbaric Oxygen Therapy Referral Form (SHA 0401)
(PDF 712.69 KB)
Published April 3, 2024

I

i-gel® - Supraglottic Airways Skills Checklist (SHA 0342)
(PDF 582.49 KB)
Published October 18, 2023
Impella CP Flowsheet - Coronary Care Unit (SHA 0471)
(PDF 261.75 KB)
Published October 16, 2024
Implementation Checklist - Eat Sleep Console (SHA 0397)
(PDF 688.41 KB)
Published March 11, 2024
Indwelling Catheter Maintenance Record (SHA 0328)
(PDF 867.01 KB)
Published September 1, 2023
Infant Exam - Midwifery (SHA 0294)
(PDF 426.47 KB)
Published July 14, 2023
Influenza Vaccine Consent - Unaccompanied Child (SHA 0148)
(PDF 216.98 KB)
Published September 22, 2021
Influenza/COVID-19 Immunization Program - Skills Checklist (SHA 0153)
(PDF 598.11 KB)
Published September 17, 2024
Initial Competency Assessment - SANE (SHA 0393)
(PDF 492.98 KB)
Published February 26, 2024
Inlow's 60 Second Diabetic Foot Screening Tool (SHA 0258)
(PDF 582.58 KB)
Published April 19, 2024
Intermittent Catheter Maintenance Record (SHA 0329)
(PDF 439.93 KB)
Published September 1, 2023
IPAC Progress Note - Downtime (SHA 0283)
(PDF 447.75 KB)
Published June 8, 2023
Iron Deficiency Anemia Management Program Fax Template (SHA 0472)
(PDF 134.53 KB)
Published October 18, 2024

J - K - L

Joint Replacement Discharge Care Plan (SHA 0323)
(PDF 477.49 KB)
Published March 25, 2024
Joint Replacement Patient Care Plan (SHA 0319)
(PDF 628.01 KB)
Published February 7, 2024
Joint Replacement Patient Care Plan SUPPLEMENT (SHA 0320)
(PDF 474.96 KB)
Published March 25, 2024
Joint Replacement Therapies Assessment (SHA 0321)
(PDF 493.69 KB)
Published February 7, 2024
Joint Replacement Therapies Progress Note (SHA 0322)
(PDF 470.42 KB)
Published February 7, 2024
Kidney Health Clinic Referral (SHA 0360)
(PDF 448.71 KB)
Published November 13, 2023
Kidney Stone Prevention Clinic Referral (SHA 0446)
(PDF 115.76 KB)
Published October 17, 2024
LAB - Anatomical Pathology Consult Requisition - REGINA (SHA 155-REG)
(PDF 605.13 KB)
Published November 13, 2024
LAB - COVID-19 Pandemic Requisition (SHA 0055)
(PDF 300.55 KB)
Published March 4, 2022
Lower Limb Assessment Form - General and Advanced (SHA 0157)
(PDF 900.47 KB)
Published December 6, 2023

M

MAID - Foreseeable Death Patient Checklist (SHA 0440)
(PDF 483.69 KB)
Published September 3, 2024
MAID - Non-Foreseeable Death Patient Checklist (SHA 0441)
(PDF 466.74 KB)
Published September 3, 2024
Malnutrition Screening Record - Dietitian – Downtime (SHA 0264)
(PDF 459.66 KB)
Published November 1, 2024
Metabolic Program - Intake Form (SHA 0289)
(PDF 559.29 KB)
Published August 23, 2023
MHAIS - Injectable Medication Visit (SHA 0252)
(PDF 426.32 KB)
Published May 9, 2023
Modified Barium Swallow (MBS) Report - Adult (SHA 0454)
(PDF 463.97 KB)
Published October 3, 2024
Mpox Contact Investigation Worksheet (SHA 0227)
(PDF 495.61 KB)
Published July 6, 2022
My Safety Plan - Long Term Care (SHA 0339)
(PDF 439.54 KB)
Published September 10, 2024

N

Newborn Care Record - Midwifery (SHA 0295)
(PDF 457.61 KB)
Published July 14, 2023
Newborn Exam - Midwifery (SHA 0299)
(PDF 528.1 KB)
Published July 14, 2023
Newborn Hearing Screening Requisition (SHA 0250)
(PDF 713 KB)
Published January 6, 2023
Nursing Assessment - Kidney Stone Prevention Clinic (SHA 0438)
(PDF 627.58 KB)
Published October 17, 2024
Nutrition - Home Nutrition Plan - NICU (SHA 0496)
(PDF 115.19 KB)
Published November 14, 2024
Nutrition Assessment - Pediatric Outpatient Initial (SHA 0495)
(PDF 146.48 KB)
Published November 14, 2024
Nutrition Assessment and Care Plan - Outpatient Adult (SHA 0494)
(PDF 477.51 KB)
Published November 14, 2024
Nutrition Assessment Record - LTC (SHA 0492)
(PDF 646.46 KB)
Published November 12, 2024
Nutrition Progress Note - Dietitian – Downtime (SHA 0265)
(PDF 119.54 KB)
Published November 1, 2024
Nutrition Progress Note – Outpatient Pediatric (SHA 0493)
(PDF 482.59 KB)
Published November 14, 2024
​Nasal High Air Flow Monitoring Record (SHA 0129)
(PDF 315.41 KB)
Published April 22, 2022

O

Ocular Donor Assessment Form (SHA 0427)
(PDF 605.72 KB)
Published July 11, 2024
OOH Labour Assessment - Midwifery (SHA 0296)
(PDF 428.17 KB)
Published July 14, 2023
OOH Labour/Birth Summary - Midwifery (SHA 0298)
(PDF 444.37 KB)
Published July 14, 2023
Opioid Agonist Therapy - Clinical Note (SHA 0254)
(PDF 487.45 KB)
Published January 18, 2023
Opioid Agonist Therapy - Initial Visit (SHA 0253)
(PDF 489.31 KB)
Published January 18, 2023

P

PACSLAC-II Single Assessment (SHA 0224)
(PDF 746.91 KB)
Published June 6, 2022
Pain Assessment Documentation - Long Term Care/Home Care (SHA 0365)
(PDF 825.11 KB)
Published November 24, 2023
PAINAD - Pain Assessment IN Advanced Dementia (SHA 0231)
(PDF 696.78 KB)
Published August 24, 2022
Palliative Care Referral Form (SHA 0434)
(PDF 615.95 KB)
Published September 13, 2024
Palliative Performance Scale (SHA 0288)
(PDF 564.73 KB)
Published August 23, 2023
Patient Booking System - Intake Request (SHA 0396)
(PDF 589.12 KB)
Published March 6, 2024
Patient Care Plan - Kidney Health (SHA 0292)
(PDF 459.25 KB)
Published July 7, 2023
Patient Face Sheet - Advanced Care Planning Program (SHA 0305)
(PDF 536.41 KB)
Published August 1, 2023
Patient Intake Form - Kidney Health (SHA 0293)
(PDF 436.79 KB)
Published July 7, 2023
Patient Notification of Transfusion (SHA 0480)
(PDF 115.02 KB)
Published November 6, 2024
Pelvic Floor Pathway Clinic Referral (SHA 0260)
(PDF 549.45 KB)
Published May 9, 2023
Poison Centre Documentation Form (SHA 0411)
(PDF 511.37 KB)
Published April 30, 2024
Post Fall Record (SHA 0362)
(PDF 257.42 KB)
Published October 10, 2024
Postpartum Care Record - Midwifery (SHA 0301)
(PDF 454.05 KB)
Published July 14, 2023
Postpartum Hemorrhage Equipment List (SHA 0428)
(PDF 548.3 KB)
Published August 27, 2024
Practitioner Admission Note - Downtime (SHA 0402)
(PDF 510.22 KB)
Published July 15, 2024
Practitioner Consultation Request Note - Downtime (SHA 0404)
(PDF 495.6 KB)
Published July 15, 2024
Practitioner Discharge Summary Note - Downtime (SHA 0403)
(PDF 538.42 KB)
Published July 15, 2024
Practitioner Procedure Note - Downtime (SHA 0408)
(PDF 488.59 KB)
Published July 15, 2024
Practitioner Progress Note - Daily - Downtime (SHA 0406)
(PDF 464.45 KB)
Published July 15, 2024
Practitioner Progress Note – Brief - Downtime (SHA 0407)
(PDF 461.08 KB)
Published July 15, 2024
Private Care Provider Checklist (SHA 0457)
(PDF 464.41 KB)
Published October 1, 2024
Provincial Prescription Pad (SHA 0141)
(PDF 47.59 KB)
Published July 16, 2021
Public Health - Request for Previously Reported Cases SHA 0383)
(PDF 880.09 KB)
Published April 3, 2024

Q-R

Quantitative Blood Loss Cumulative Total Record (SHA 0429)
(PDF 666.79 KB)
Published August 27, 2024
RAAM Suicide Risk Assessment (SHA 0060)
(PDF 209.58 KB)
Published June 18, 2020
Rapid Access Single Seizure (RASS) Clinic Referral Form (SHA 0484)
(PDF 149.09 KB)
Published October 30, 2024
Renal Transplant Assessment Referral Form (SHA 0287)
(PDF 617.1 KB)
Published July 5, 2023
Request for Access to Medical Images (SHA 0145)
(PDF 322.28 KB)
Published September 14, 2021
Request for Private Care Provider Form (SHA 0456)
(PDF 604.6 KB)
Published October 1, 2024
Request for Private Provider (SHA 0358)
(PDF 444.66 KB)
Published November 7, 2023

S

SAFE-T Protocol with C-SSRS - LTC Suicide Prevention (SHA 0338)
(PDF 790.05 KB)
Published September 10, 2024
Scott Fall Risk Screening Tool for Residential Care (SHA 0363)
(PDF 790.19 KB)
Published November 22, 2023
Sexual Assault Examination Guide Record - SANE (SHA 0317)
(PDF 1.69 MB)
Published September 1, 2023
Sexual Assault Follow Up Letter - Practitioner (SHA 0316)
(PDF 618.9 KB)
Published June 18, 2024
Sexual Assault Health Provider Communication Tool - SANE (SHA 0349)
(PDF 514.22 KB)
Published October 31, 2023
SHA Donation Program - Progress Notes - SCM Downtime (SHA 0257)
(PDF 425.73 KB)
Published March 7, 2023
Skin and Wound Care Audit - Data Collection Sheet (SHA 0361)
(PDF 695.68 KB)
Published December 6, 2023
Skin Inspection and Bath Water Temperature Checks (SHA 0302)
(PDF 742.55 KB)
Published October 11, 2023
Stroke Screen - Rural (SHA 0359)
(PDF 608.64 KB)
Published January 22, 2024
Symptom Assessment Acronym Tool - OPQRSTUV (SHA 0234)
(PDF 527.87 KB)
Published October 7, 2022
Syphilis - Contact PCP Letter (SHA 0381)
(PDF 897.25 KB)
Published July 5, 2024
Syphilis - Final Notice Letter (SHA 0312)
(PDF 851.83 KB)
Published January 10, 2024
Syphilis in Pregnancy - Treatment and Serology Summary (SHA 0382)
(PDF 892.88 KB)
Published December 22, 2023
Syphilis Reactive Serology - Practitioner Checklist (SHA 0239)
(PDF 617.43 KB)
Published April 8, 2024
Syphilis Screening - Pregnancy (SHA 0284)
(PDF 642.49 KB)
Published June 28, 2023

T - U

Therapy Services Progress Note (SHA 0356)
(PDF 445.43 KB)
Published October 31, 2023
Transfusion Administration Record (TAR) (SHA 0479)
(PDF 249.73 KB)
Published November 8, 2024
Triage Assessment Record - ADULT (SHA 0079)
(PDF 242.58 KB)
Published May 13, 2022
Triage Assessment Record​​ - PEDIATRIC (SHA 0080)
(PDF 246.74 KB)
Published May 13, 2022
Urgent Care Centre - Discharge Summary (SHA 0432)
(PDF 660.29 KB)
Published June 28, 2024
Urgent Care Centre - Patient Care Record (SHA 0431)
(PDF 478.02 KB)
Published June 28, 2024
Urgent Care Centre - Primary Assessment (SHA 0430)
(PDF 513.42 KB)
Published June 28, 2024
Urinary Catheter Irrigation Record (SHA 0330)
(PDF 437.45 KB)
Published September 1, 2023

V - Y

Vaccine Consent​ WITH Substitute Decision Maker​​ (SHA 0096)
(PDF 651.57 KB)
Published November 19, 2024
Vancomycin Monitoring Form - Adult (SHA 0216)
(PDF 464.97 KB)
Published September 21, 2022
Virtual Care Appointment Record (SHA 0030)
(PDF 459.59 KB)
Published November 16, 2023
Weekly Support Surface Checklist - Long Term Care (LTC) (SHA 0437)
(PDF 503.83 KB)
Published October 31, 2024

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