Quarterly Patient Information Form

Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care

Att 7a_Quarterly patient information form

Quarterly Patient Information Form

OMB: 0920-1019

Document [docx]
Download: docx | pdf

Attachment 7 Patient Project ID: __________

Staff Project ID: __________

Clinic Project ID: __________



Form Approved

OMB No: 0920-XXXX

Exp. Date: XX/XX/XXXX







Quarterly Patient Information Form







Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)







_________________________________________________________________________________________



FOR PARTNERED SITES USE ONLY

Have there been any changes to the patient’s or clinic’s contact information? □ yes □ no

If yes, please complete the following table:

FOR PROGRAM USE ONLY

Patient information

Address:

City:

State:

Zip code:

Phone number: (____) _______-_______

home

mobile

Phone number: (____) _______-_______

home

mobile

Email address:

Clinic information

Provider name:

Clinic name:

Clinic phone number: (____) _______-_______

Clinic fax number: (____) _______-_______

Primary clinic contact person:

Contact phone number: (____) _______-_______

Email address:

Secondary clinic contact person:

Contact phone number: (____) _______-_______

Email address:





_______________________________________________________________________________________









Quarterly Patient Information Form


Date: ___/___/____


Patient Project ID: _______________



Has patient had a medical visit with a physician, nurse practitioner or physician’s assistant since the last quarterly review? □ yes □ no


If patient did not have medical visit with a physician, nurse practitioner or physician’s assistant since the last quarterly review, has the patient been seen in the clinic for any reason (e.g. case management, mental health) or had labs drawn in the past 6 months?

□ yes □ no




If no, state the reason why the patient is not continuing care or has not been seen in the clinic in the past 6 months


□ Patient has missed scheduled appointments date: ____/_____/______ □ Unknown


Patient died date: ____/_____/______ □ Unknown


□ Patient too ill (e.g. hospitalized, nursing home, hospice care) date: ____/_____/______ □ Unknown


□ Moved out of area date: ____/_____/______ □ Unknown


□ Transferred care to another provider date: ____/_____/______ □ Unknown


□ Incarcerated date: ____/_____/______ □ Unknown


□ Voluntary withdraw from project date: ____/_____/______ □ Unknown


□ Don’t know/ unsure what happened to patient date: ____/_____/______ □ Unknown


□ Other: ______________________________ date: ____/_____/______ □ Unknown



*If patient has not been seen in the clinic for any reason AND has not had labs drawn in the past 6 months, STOP





Patient Information

Has there been a change in insurance status?: □ no □ yes, patient has a new insurer □ yes, patient is no longer insured □ Unknown

If patient has a new insurer please provide the name of new insurer: __________________


Most recent Weight: ________________ (lbs/kg (circle)) Date: ___/___/____

All dates should be in the MM/DD/YYYY format


Was patient’s blood pressure taken since the last quarterly update? □ no □ yes

If yes, please provide patient’s blood pressure values since the last quarterly update

Blood pressure: ___/____ Date: ___/___/____

Blood pressure: ___/____ Date: ___/___/____

Blood pressure: ___/____ Date: ___/___/____


I. Patient Lab Information:


A. Please update lab information since the last quarterly review

Laboratory Tests

Value/Date

Value/Date

Value / Date

Value/Date

CD4

(cells/ µL and %)


Was lab drawn?

□ no □ yes




_____ cells/µL _____ %


___/___/____


pending


_____ cells/µL _____ %


___/___/____


pending


_____ cells/µL _____ %


___/___/____


pending

_____ cells/µL

_____ %


___/___/____


pending

HIV-1 RNA/DNA NAAT (Quantitative viral load)

(copies/mL)


Was lab drawn?

□ no □ yes


Copies/mL: __________


___/___/____


pending


Copies/mL ___________


___/___/____


pending


Copies/mL ___________


___/___/____


pending


Copies/mL _____________


___/___/____


pending





B. Please update laboratory information since the last quarterly review


Laboratory Test/Screenings

Value/Date

Value/Date

Value / Date

Value/Date

Total Cholesterol

(mg/dL)


Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

LDL:

(mg/dL)



Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

HDL:

(mg/dL)


Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

TG:

(mg/dL)



Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

HbA1c (only if diagnosed with diabetes):



Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

Glucose:

(mg/dL)


Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

Hemoglobin:


Was lab drawn?

no □ yes


________


pending


________


pending


________


pending


________


pending

LFTs

(units/L)




Was lab drawn?

no □ yes


ALT _______


AST _______


___/___/____


pending



ALT _______


AST _______


___/___/____


pending


ALT _______


AST _______


___/___/____


pending


ALT _______


AST _______


___/___/____


pending

Bilirubin

(mg/dL)



Was lab drawn?

no □ yes


________


___/___/____


□ pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


□ pending

Creatinine




Was lab drawn?

no □ yes


________



___/___/____


pending


________



___/___/____


pending


________



___/___/____


pending


________



___/___/____


pending

Urinalysis




Was lab done?

no □ yes

+ protein

- protein


___/___/____


pending

+ protein

- protein


___/___/____


pending

+ protein

- protein


___/___/____


pending

+ protein

- protein


___/___/____


pending

Was a basic chemistry

panel completed?

Y / N


___/___/____


pending

Y / N


___/___/____


pending

Y / N


___/___/____


pending

Y / N


___/___/____


pending

HBV DNA

(if HBV co-infected)

(copies/mL)


Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

HCV RNA

(if HCV co-infected)

(copies/mL)



Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

Syphilis screening


Was lab drawn?

no □ yes

negative

positive


___/___/____


pending

negative

positive


___/___/____


pending

negative

positive


___/___/____


pending

negative

positive


___/___/____


pending

N/A = not applicable


C. Please provide the following information on viral hepatitis testing since the last quarterly review

Viral Hepatitis

Has the patient been tested for HBsAg* since the last quarterly update?

□ yes

□ no

□ Unknown


If yes, results:

□ negative

□ positive

Has the patient been tested for anti-HBs^ since the last quarterly update?

□ yes

□ no

□ Unknown


If yes, results:

□ >10 mIU/mL

□ < 10 mIU/mL

Has the patient been tested for anti-HCVǂ since the last quarterly update?

□ yes

□ no

□ Unknown


If yes, results:

□ negative

□ positive

If anti-HCV test was positive, was a confirmatory test done?

□ yes

□ no

□ Unknown


If yes, results:

□ negative

□ positive

*HBsAg = hepatitis B surface antigen

^Anti-HBs = antibody to the hepatitis B surface antigen

ǂAnti-HCV = antibody to hepatitis C virus



II. Medication Updates



A1. Please list all antiretroviral therapy (ART) medications that the patient currently takes (at the time of quarterly update)


Name of current ART medications

Dosage

Frequency

Start date





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____



Have there been any changes to the patient’s ART since last quarterly update? □ no □ yes

Has an HLA-B*5701 test been done? □ yes □ no

If yes, what was the result of the HLA-B*5701 test? □ negative □ positive

Has a tropism assay been done? □ yes □ no

If yes, what were the results?

□ CCR5 positive □ CXCR4 positive □ dual or mixed tropism


A2. List all NEW ART medications initiated since last quarterly update


Name of new ART medication

Dosage

Frequency

Start date





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____





A3. List all discontinued ART medications since last quarterly update


Name of discontinued ART medication

Date discontinued

Reason for discontinuation



___/___/____

□ tolerability □ toxicity / side effects

□ failure □ other ___________



___/___/____

□ tolerability □ toxicity / side effects

□ failure □ other ___________



___/___/____

□ tolerability □ toxicity / side effects

□ failure □ other ___________



___/___/____

□ tolerability □ toxicity / side effects

□ failure □ other ___________



___/___/____

□ tolerability □ toxicity / side effects

□ failure □ other ___________



___/___/____

□ tolerability □ toxicity / side effects

□ failure □ other ___________





B1. Please list all other medications that the patient currently takes (at the time of quarterly update)


Name of other current medication

Dosage

Frequency

Start date





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____



Have there been any changes to the patient’s other medications (non-HIV medications) since last quarterly update? □ no □ yes






B2. List all NEW non-HIV medications initiated since last quarterly update



Name of new non-HIV medication

Dosage

Frequency

Reason for Initiation

Start date






___/___/____






___/___/____






___/___/____






___/___/____






___/___/____






___/___/____



B3. List all discontinued non-HIV medications since last quarterly update


Name of discontinued non-HIV medication

Date discontinued

Reason for discontinuation



___/___/____

□ tolerability □ toxicity / side effects

□ failure □ no longer indicated □ other ___________



___/___/____

□ tolerability □ toxicity / side effects

□ failure □ no longer indicated □ other ___________



___/___/____

□ tolerability □ toxicity / side effects

□ failure □ no longer indicated □ other ___________



___/___/____

□ tolerability □ toxicity / side effects

□ failure □ no longer indicated □ other ___________



___/___/____

□ tolerability □ toxicity / side effects

□ failure □ no longer indicated □ other ___________



___/___/____

□ tolerability □ toxicity / side effects

□ failure □ no longer indicated □ other ___________







III. Medical History and Allergies Updates


A. Were there any newly diagnosed medical conditions or problems at any time since the last quarterly update? yes □ no


If yes, list all newly diagnosed medical conditions and problems

Newly diagnosed medical conditions or new medical problems

Date diagnosed



___/___/____



___/___/____



___/___/____



___/___/____



___/___/____



___/___/____


B. Were there any resolved medical problems at any time since the last quarterly visit?

yes □ no


If yes, list all resolved medical problems


Resolved medical problems

Date resolved



___/___/____



___/___/____



___/___/____



___/___/____



___/___/____



___/___/____





C. Were they any newly diagnosed drug allergies since the last quarterly update? □ yes □ no

If yes, list all new drug allergies

Name of medication

Reaction to medication

Date allergy developed




___/___/____




___/___/____




___/___/____




___/___/____




___/___/____




___/___/____



IV. Tobacco, Drug and Alcohol use



Has patient’s smoking status changed since last quarterly update?

□ yes

□ no

□ Unknown

If yes, how has smoking status changed?

N/A

□ increased amount smoked

□ decreased amount smoked

□ new smoker Date started: ___/___/____

□ quit smoking Date quit: ___/___/____

Has patient’s illegal drug use/abuse of prescription controlled substances changed since last quarterly update?

□ yes


□ no

□ Unknown

If yes, how has drug abuse status changed?

N/A

□ increased amount used

□ decreased amount used

□ new user Date started: ___/___/____

□ quit using Date quit: ___/___/____

Has patient initiated or completed substance abuse treatment since last quarterly update?

□ N/A

□ yes, currently in a program

□ yes, completed a program

□ no

□ Unknown

Has patient’s heavy alcohol consumption changed since last quarterly update?

Heavy alcohol consumption for males equals ≥5 drinks on any single day or ≥15 drinks per week; for women heavy alcohol consumption equals ≥4 drinks on any single day or ≥8 drinks per week

□ yes

□ no

□ Unknown

If yes, how has alcohol consumption changed?

N/A

□ increased drinking

□ decreased drinking

□ new heavy drinker Date started: ___/___/____

□ quit drinking Date quit: ___/___/____

Has patient initiated or completed alcohol abuse treatment since last quarterly update?

□ N/A

□ yes, currently in a program

□ yes, completed a program

□ no




V. Immunization History


Did client receive any immunizations at this clinic since last quarterly update? □ yes □ no

If yes, which immunization(s) was provided? ____________________ date ____/_____/______

____________________ date ____/_____/______


____________________ date ____/_____/______





VI. Clinic Appointment Information


Was patient scheduled for any appointments (e.g. medical, case management, mental health, substance abuse) since last quarterly update? □ yes □ no □ Unknown


If yes, please list ALL appointments (medical, case management, mental health, substance abuse) scheduled for the patient since the last quarterly update and note if appointment was kept

Include only one appointment type and date in each box

Type of appointment Date Was appt. kept?

Type of appointment Date Was appt. kept?

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

*a medical appointment with a physician, nurse practitioner or physician’s assistant

appointment with Case management or a Social Worker





VII. Medication Therapy Management (MTM)



Was documentation of patient’s MTM visit(s) received by the clinic? □ yes □ no

If yes, complete the following table for each MTM communication received since last quarterly update:

Date MTM information received at clinic

How MTM information was sent to clinic

Did provider acknowledge receipt of MTM information?


____/_____/_____

□ fax □ in person □ other __________

□ yes date: ____/_____/_____

□ no

□ unknown


____/_____/_____

□ fax □ in person □ other __________

□ yes date: ____/_____/_____

□ no

□ unknown


____/_____/_____

□ fax □ in person □ other __________

□ yes date: ____/_____/_____

□ no

□ unknown


____/_____/_____

□ fax □ in person □ other __________

□ yes date: ____/_____/_____

□ no

□ unknown


____/_____/_____

□ fax □ in person □ other __________

□ yes date: ____/_____/_____

□ no

□ unknown



VII. Follow-up



When is patient’s next scheduled medical appointment with a physician, nurse practitioner or physician’s assistant?


date: ____/_____/______ □ no appointment scheduled



When is patient’s next scheduled Medication Therapy Management (MTM) appointment?


date: ____/_____/______ □ no appointment scheduled



NOTES: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________






ADDITIONAL LABORATORY TEST VALUES

(use if needed to record additional laboratory test values)


Please provide the following laboratory values for the past 24 months

Laboratory Tests

Value/Date

Value/Date

Value / Date

Value/Date

CD4

(cells/ µL and %)


Was lab drawn?

□ no □ yes




_____ cells/µL _____ %


___/___/____


pending


_____ cells/µL _____ %


___/___/____


pending


_____ cells/µL _____ %


___/___/____


pending

_____ cells/µL

_____ %


___/___/____


pending

HIV-1 RNA/DNA NAAT (Quantitative viral load)

(copies/mL)


Was lab drawn?

□ no □ yes


Copies/mL: __________


___/___/____


pending


Copies/mL ___________


___/___/____


pending


Copies/mL ___________


___/___/____


pending


Copies/mL _____________


___/___/____


pending


Please provide the following laboratory values for the past 12 months:

Laboratory Test/Screenings

Value/Date

Value/Date

Value / Date

Value/Date

Total Cholesterol

(mg/dL)


Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

LDL:

(mg/dL)



Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

HDL:

(mg/dL)


Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

TG:

(mg/dL)



Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

HbA1c (only if diagnosed with diabetes):



Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

Glucose:

(mg/dL)


Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

Hemoglobin:


Was lab drawn?

no □ yes


________


pending


________


pending


________


pending


________


pending

LFTs

(units/L)




Was lab drawn?

no □ yes


ALT _______


AST _______


___/___/____


pending



ALT _______


AST _______


___/___/____


pending


ALT _______


AST _______


___/___/____


pending


ALT _______


AST _______


___/___/____


pending

Bilirubin

(mg/dL)



Was lab drawn?

no □ yes


________


___/___/____


□ pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


□ pending

Creatinine




Was lab drawn?

no □ yes


________



___/___/____


pending


________



___/___/____


pending


________



___/___/____


pending


________



___/___/____


pending

Urinalysis




Was lab done?

no □ yes

+ protein

- protein


___/___/____


pending

+ protein

- protein


___/___/____


pending

+ protein

- protein


___/___/____


pending

+ protein

- protein


___/___/____


pending

Was a basic chemistry

panel completed?

Y / N


___/___/____


pending

Y / N


___/___/____


pending

Y / N


___/___/____


pending

Y / N


___/___/____


pending

HBV DNA

(if HBV co-infected)

(copies/mL)


Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

HCV RNA

(if HCV co-infected)

(copies/mL)



Was lab drawn?

no □ yes


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending


________


___/___/____


pending

Syphilis screening


Was lab drawn?

no □ yes

negative

positive


___/___/____


pending

negative

positive


___/___/____


pending

negative

positive


___/___/____


pending

negative

positive


___/___/____


pending
















ADDITIONAL CLINIC APPOINTMENT INFORMATION

(use if needed to record clinic appointment information)


Type of appointment Date Was appt. kept?

Type of appointment Date Was appt. kept?

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

Medical visit* ____/_____/_____ □ yes □ no

Case management Unknown

Mental Health

Substance Abuse

*a medical appointment with a physician, nurse practitioner or physician’s assistant

appointment with Case management or a Social Worker



Quarterly Patient Information Form Page 15 of 15


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