Clinical Forms – A to M

CTRL + F - SEARCH TIP

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. 

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
ACPP Yellow Sleeve Sticker (SHA 0664)
(PDF 110.9 KB)
Published November 19, 2025
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
Acute Exacerbation COPD Bundle Audit Form (SHA 0597)
(PDF 157.45 KB)
Published June 18, 2025
Adult Inpatient Fall Risk Assessment (SHA 0656)
(PDF 247.54 KB)
Published March 10, 2026
Advance Care Planning Documentation Record (SHA 0325)
(PDF 170.47 KB)
Published March 9, 2026
ALS/MND Clinic - Spirometry Report (SHA 0500)
(PDF 123.05 KB)
Published November 19, 2024
Alternate Level of Care (ALC) Form - Provincial (SHA 0528)
(PDF 143.02 KB)
Published January 14, 2025
Ambulatory Care Flow Sheet - SASKATOON (SHA 0548)
(PDF 795.65 KB)
Published February 5, 2025
Ambulatory Care Procedure Note – REGINA (SHA 0544)
(PDF 115.32 KB)
Published January 30, 2025
Anaphylaxis Treatment Worksheet (SHA 0232)
(PDF 495.08 KB)
Published September 12, 2022
Anesthesiology Difficult Airway Assessment Alert (SHA 0670)
(PDF 239.52 KB)
Published December 3, 2025
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 265.33 KB)
Published January 13, 2025
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 Initial Questionnaire (SHA 0156)
(PDF 363.71 KB)
Published June 17, 2025
Breast Health Centre Questionnaire (SHA 0560)
(PDF 207.15 KB)
Published April 4, 2025
Breast Health Centre Referral Form (SHA 0409)
(PDF 245.52 KB)
Published September 15, 2025
Breastfeeding/Chestfeeding Assessment Tool (SHA 0345)
(PDF 737.94 KB)
Published December 14, 2023
Bridge Clinic Referral - Saskatoon (SHA 0679)
(PDF 269.58 KB)
Published January 21, 2026
Brief Alcohol Withdrawal Scale (BAWS) (SHA 0682)
(PDF 118.47 KB)
Published January 26, 2026

C

Cardiac Amyloidosis Referral (SHA 0690)
(PDF 247.93 KB)
Published February 12, 2026
Caregiver Pronouncement Plan - Expected Death at Home (SHA 0158)
(PDF 164.25 KB)
Published October 1, 2025
Cast Clinic Assessment Guide - Ambulatory Care (SHA 0598)
(PDF 144.54 KB)
Published June 12, 2025
Clinical Nurse Specialist Notes - Stroke (SHA 0380)
(PDF 147.31 KB)
Published November 25, 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 170.79 KB)
Published October 6, 2025
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
Crisis Response Plan - Patient Version (SHA 0571)
(PDF 724.15 KB)
Published December 1, 2025

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
Diabetes Services Adult Client Assessment (SHA 0513)
(PDF 157.46 KB)
Published March 25, 2026
Diet Order Form - Acute Care Hospital - Adult (SHA 0498)
(PDF 146.05 KB)
Published March 18, 2026
Diet Order Form - Acute Care Hospital - Pediatric (SHA 0703)
(PDF 144.22 KB)
Published March 18, 2026
Diet Order Form - LTC Home (SHA 0499)
(PDF 141.25 KB)
Published March 17, 2026
Dietitian Referral Form - Continuing Care (SHA 0206)
(PDF 210.03 KB)
Published March 7, 2022
Diluent and Vaccine Box Labels - 10 Doses (SHA 0580)
(PDF 126.84 KB)
Published December 23, 2025
Diluent and Vaccine Box Labels - 5 Doses (SHA 0581)
(PDF 149.45 KB)
Published December 23, 2025
Discharge Care Plan - Stroke (SHA 0565)
(PDF 258.88 KB)
Published April 14, 2025
Discharge Instructions for Baby - HIV Prevention (SHA 0151)
(PDF 350.48 KB)
Published May 2, 2022
Discharge Summary - Therapy Services - Psychology (SHA 0578)
(PDF 130.33 KB)
Published September 17, 2025
Discharge Summary Sheet - Kidney Health Clinic (SHA 0391)
(PDF 463.92 KB)
Published January 31, 2024
DOT Medication Record - TB (SHA 0370)
(PDF 517.76 KB)
Published November 27, 2024
Drug Checking Intake and Sample Drop Off Form (SHA 0669)
(PDF 221.84 KB)
Published March 3, 2026

E

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 Outpatient (SHA 0340)
(PDF 161.55 KB)
Published March 25, 2025
Edmonson Psychiatric Fall Risk Assessment (SHA 0657)
(PDF 213.01 KB)
Published March 10, 2026
Electronic Communications Consent Form (SHA 0543)
(PDF 194.73 KB)
Published April 2, 2025
Employee Competency Assessment Review (SHA 0529)
(PDF 130.23 KB)
Published January 21, 2025
EMS and Community Paramedicine Services Referral Form (SHA 0203)
(PDF 299.4 KB)
Published December 16, 2025
EndoAVF Nurse-to-Nurse Handover for Transient Patients (SHA 0692)
(PDF 232.14 KB)
Published February 17, 2026
Enteral Feeding Bundle - Implementation Checklist (SHA 0510)
(PDF 309.32 KB)
Published January 9, 2025
Enteral Feeding Resources Mom & Kids (SHA 0674)
(PDF 290.6 KB)
Published December 9, 2025
Enteral Tube Feed Flow Sheet (SHA 0530) - OPTIONAL TO USE
(PDF 180.6 KB)
Published March 27, 2025

F

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
Falls Tracking Tool Acute Care Inpatient (SHA 0660)
(PDF 753.16 KB)
Published March 10, 2026
Fentanyl Drug Checking Strips [AVERY Labels 5164] (SHA 0553)
(PDF 376.15 KB)
Published March 13, 2025
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

General Anxiety Disorder - GAD-7 (SHA 0251)
(PDF 140.58 KB)
Published January 18, 2023
Green Sleeve Audit Tool (SHA 0639)
(XLSX 41.59 KB)
Published October 6, 2025
Green Sleeve Label - Expected Death at Home (SHA 0160)
(PDF 202.4 KB)
Published October 1, 2025

H

Handover Report - Hemodialysis - REGINA (SHA 0610)
(PDF 270.4 KB)
Published July 8, 2025
Handover Report - Hemodialysis - SASKATOON (SHA 0611)
(PDF 172.62 KB)
Published September 17, 2025
Handover Report - Inpatient Psychiatry to Acute Care (SHA 0505)
(PDF 183.15 KB)
Published November 21, 2024
Heart Function Clinic - Understanding Participation in HFC (SHA 0695)
(PDF 181.81 KB)
Published February 23, 2026
Heart Function Clinic Graduation Criteria (SHA 0694)
(PDF 134.71 KB)
Published February 23, 2026
Heart Function Clinic Outpatient Intake Interview (SHA 0693)
(PDF 209.33 KB)
Published February 23, 2026
Heart Function Clinic Referral Form (SHA 0696)
(PDF 216.09 KB)
Published February 23, 2026
HIV PEP Kit Replacement Form (SHA 0315)
(PDF 714.56 KB)
Published February 1, 2024
HIV Self-Test Kit Application Form (SHA 0561)
(PDF 191.17 KB)
Published July 10, 2025
HIV Self-Test Kit Tracking Form (SHA 0563)
(PDF 189.67 KB)
Published April 14, 2025
HIV Self-Testing Kits Order Form (SHA 0562)
(PDF 173.98 KB)
Published February 20, 2026
Home Adult Total Parenteral Nutrition Referral Form (SHA 0634)
(PDF 163.54 KB)
Published November 13, 2025
Human Factors Analysis for Patient Safety Incidents (SHA 0461)
(PDF 622.09 KB)
Published March 3, 2025
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 310.72 KB)
Published June 26, 2025
Implementation Checklist - Eat Sleep Console (SHA 0397)
(PDF 688.41 KB)
Published March 11, 2024
Indwelling Catheter Maintenance Record (SHA 0328)
(PDF 252.4 KB)
Published August 22, 2025
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 217.77 KB)
Published September 19, 2025
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
Intake Report - Therapy Services - Psychology (SHA 0576)
(PDF 150.88 KB)
Published September 17, 2025
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
IVIG Orders Physician Checklist (SHA 0687)
(PDF 319.03 KB)
Published February 6, 2026

J

JADA® Evaluation Survey (SHA 0591)
(PDF 148.42 KB)
Published June 16, 2025
Joint Replacement Discharge Care Plan (SHA 0323)
(PDF 280.78 KB)
Published July 1, 2025
Joint Replacement Patient Care Plan (SHA 0319)
(PDF 228.51 KB)
Published July 1, 2025
Joint Replacement Patient Care Plan SUPPLEMENT (SHA 0320)
(PDF 152.58 KB)
Published July 1, 2025
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

K

Kidney Health Clinic Referral (SHA 0360)
(PDF 448.71 KB)
Published November 13, 2023
Kidney Health Clinical Profile (SHA 0292)
(PDF 172.72 KB)
Published March 24, 2025
Kidney Stone Prevention Clinic Referral (SHA 0446)
(PDF 115.76 KB)
Published October 17, 2024

L

LAB - COVID-19 Pandemic Requisition (SHA 0055)
(PDF 300.55 KB)
Published March 4, 2022
Long Term Care Moving-In Agreement (SHA 0526)
(PDF 168.97 KB)
Published January 20, 2025
Lower Limb Assessment Form - General and Advanced (SHA 0157)
(PDF 900.47 KB)
Published December 6, 2023

M

MAID - Assessor/Provider Profile (SHA 0604)
(PDF 163.96 KB)
Published July 5, 2025
MAID - Foreseeable Death Patient Checklist (SHA 0440)
(PDF 159.34 KB)
Published November 12, 2025
MAID - Non-Foreseeable Death Patient Checklist (SHA 0441)
(PDF 144.46 KB)
Published November 12, 2025
MAID - Practitioner Agreement (SHA 0605)
(PDF 161.3 KB)
Published July 5, 2025
Malnutrition Screening Record - Dietitian – Downtime (SHA 0264)
(PDF 459.66 KB)
Published November 1, 2024
MD Patient and Family Meeting Note (SHA 0551)
(PDF 137.08 KB)
Published December 4, 2025
Measles Contact Instructions - Unit Staff to Complete (SHA 0516)
(PDF 151.15 KB)
Published April 25, 2025
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
MRI Safety Screening Questionnaire (SHA 0632)
(PDF 3.91 MB)
Published September 7, 2025
My Safety Plan - Long Term Care (SHA 0339)
(PDF 439.54 KB)
Published September 10, 2024