Initial Patient Information Form

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

Att 6a_Initial Patient Information form

Initial Patient Information Form

OMB: 0920-1019

Document [docx]
Download: docx | pdf

Attachment 6a Patient Project ID: __________

Staff Project ID: __________

Clinic Project ID: __________



Form Approved

OMB No: 0920-XXXX

Exp. Date: XX/XX/XXXX







Initial Patient Information Form











Public reporting burden of this collection of information is estimated to average 1 hour 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



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:





-------------------------------------------------------------------------------------------------------------------------------











Date: ___/___/____



Initial Patient Information Form

I. Patient Demographic Information

Date of Birth (month/year)

_____/ ______

Sex: (check all that apply)

Male

Female

Transgender

Race (check all that apply)

White

Black/African American

Asian

Native Hawaiian/Pacific Islander

American Indian/Alaska Native

Other: __________

Ethnicity

Hispanic/Latino

Not Hispanic/Latino

Unknown

Education level

less than high school

high school only

some college

college or above

Unknown

Number of people in household: _________ Unknown

Annual household income

< $15,000

$15,000 - < $30,000

$30,000

Unknown


Housing status

currently homeless

not currently, but homeless in the past 12 months

homeless previously, but not homeless in the past 12 months

Never homeless

Unknown

Employment status (check all that apply)

unemployed

employed

disabled

student

retired

Unknown

If patient is employed, is he/she employed part time or full time?

N/A

part time

full time

Unknown

Medical Insurance status (check all that apply)

Private insurance

Medicaid

Medicare

Ryan White/ADAP

uninsured

Unknown







Date of patient’s first visit to THIS clinic: _____/______/_______ (MM/DD/YYYY)

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



II. Diagnosis Information


Date of HIV Diagnosis: ­­­_____/______/_______ (MM/DD/YYYY) □ Unknown

Disease Stage at diagnosis: □ stage 1 HIV □ stage 2 HIV □ stage 3 AIDS □ stage Unknown □ Unknown

Date first entered into care for HIV: _____/_____/______ □ Unknown

*enter the date the patient first entered into HIV care which might not be the date the patient first entered into care at this clinic


III. Patient Laboratory Information and Vital signs


A. Please provide the following information:

Height: ______________ (inches) Date: _____/_______/______

Most recent weight: ______________(lbs/kg (circle)) Date: _____/_______/______


B. Please provide patient’s blood pressure values for the past 12 months

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

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

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

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

C. Please provide the following laboratory values for the past 24 months

Please use the additional tables at the end of the form if there are more than four lab values over the past 12 months



Laboratory Test

Value/Date


Value/Date


Value/Date


Value/Date


CD4

(cells/ µL and %)


_____ cells/µL


_____ %


___/___/____


_____ cells/µL


_____ %


___/___/____


_____ cells/µL


_____ %


___/___/____

_____ cells/µL


_____ %


___/___/____

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


(copies/mL)

Copies/mL: __________



___/___/____

Copies/mL ___________



___/___/____

Copies/mL ___________



___/___/____

Copies/mL _____________



___/___/____



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

Please use the additional tables at the end of the form if there are more than four lab values over the past 12 months

Laboratory Test/Screenings

Value/Date

Value/Date

Value / Date

Value/Date

Total Cholesterol

(mg/dL)



________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


LDL:

(mg/dL)




________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


HDL:

(mg/dL)



________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


TG:

(mg/dL)




________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


HbA1c (only if diagnosed with diabetes):



________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


Glucose:

(mg/dL)



________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


Hemoglobin:



________



________



________



________


LFTs

(units/L)





ALT _______


AST _______


___/___/____




ALT _______


AST _______


___/___/____




ALT _______


AST _______


___/___/____




ALT _______


AST _______


___/___/____



Bilirubin

(mg/dL)




________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


Creatinine





________



___/___/____



________



___/___/____



________



___/___/____



________



___/___/____


Urinalysis




+ protein

- protein


___/___/____


+ protein

- protein


___/___/____


+ protein

- protein


___/___/____


+ protein

- protein


___/___/____


Was a basic chemistry

panel completed?

Y / N


___/___/____


Y / N


___/___/____


Y / N


___/___/____


Y / N


___/___/____


HBV DNA

(if HBV co-infected)

(copies/mL)



________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


HCV RNA

(if HCV co-infected)

(copies/mL)




________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


Syphilis screening


negative

positive


___/___/____


negative

positive


___/___/____


negative

positive


___/___/____


negative

positive


___/___/____


Y = yes

N = no

UNK = Unknown



E. Please provide the following information on viral hepatitis testing

Viral Hepatitis

Has the patient ever been tested for HBsAg*?

□ yes

□ no

□ Unknown


If yes, results:

□ negative

□ positive

Has the patient ever been tested for anti-HBs^?

□ yes

□ no

□ Unknown


If yes, results:

□ >10 mIU/mL

□ < 10 mIU/mL

Has the patient ever been tested for anti-HCVǂ?

□ 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



IV. Immunizationsǂ

Vaccine

Vaccination Received Ever

Number of doses

Dates

Series completed?

Hepatitis A

□ yes

□ no

□ Unknown

_______

___/___/____

___/___/____

yes

□ no

□ Unknown

Hepatitis B

□ yes

□ no

□ Unknown

_______

___/___/____

___/___/____

___/___/____

yes

□ no

□ Unknown

Hepatitis A/B

□ yes

□ no

□ Unknown

_______

___/___/____

___/___/____

___/___/____

yes

□ no

□ Unknown

Human papilloma virus

□ yes

□ no

□ Unknown

_______

___/___/____

___/___/____

___/___/____

yes

□ no

□ Unknown

Pneumococcal‡

□ yes

□ no

□ Unknown

_______

___/___/____

___/___/____

___/___/____


Influenza

□ yes

□ no

□ Unknown


___/___/____

(most recent dose)


Meningococcal‡

□ yes

□ no

□ Unknown

_______

___/___/____

___/___/____


Tetanus (Td)

□ yes

□ no

□ Unknown

_______

___/___/____

(most recent dose)


Tetanus, diphtheria, pertussis (Tdap)

□ yes

□ no

□ Unknown

_______

___/___/____


ǂ please list all immunizations ever received

includes both the conjugate and polysaccharide vaccines



V. Medication Use


A. Has patient ever taken antiretroviral therapy (ART)? □ yes □ no

If yes, what was the date of first ever ART*: ____/____/_____ □ N/A □ Unknown

*please list the date first started on ART, which may not be the date the patient started on ART at this clinic


Is patient currently taking ART? □ yes □ no

If no, date of last use: _____/_____/_____ □ N/A □ Unknown

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



B. Current ART Medications

Name of Current ART Medications*

Dosage (mg)

Frequency

Start date





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____

*Fixed dose combination medications (e.g. Atripla) should be listed on one line


C. Please provide a list of ALL former ART medications ever taken

Name of ALL Former ART Medications ever taken

Dosage (mg)

Frequency

Start date

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 ___________





___/___/____

___/___/____

□ tolerability

□ toxicity / side effects

□ failure

□ other ___________





___/___/____

___/___/____

□ tolerability

□ toxicity / side effects

□ failure

□ other ___________





___/___/____

___/___/____

□ tolerability

□ toxicity / side effects

□ failure

□ other ___________





___/___/____

___/___/____

□ tolerability

□ toxicity / side effects

□ failure

□ other ___________



D. List all medications that patient is currently taking for opportunistic infection (OI) treatment or prevention



Name of Current Medication for OIs

Name of OI

Dosage (mg)

Frequency

Start date






___/___/____

treatment

prophylaxis






___/___/____

treatment

prophylaxis






___/___/____

treatment

prophylaxis






___/___/____

treatment

prophylaxis



E. List all medications that patient has formerly taken for opportunistic infection (OI) treatment or prevention over the past 24 months

Name of Former Medication for OIs

Name of OI

Dosage (mg)

Frequency

Start date

Date Discontinued






___/___/____

___/___/____

treatment

prophylaxis






___/___/____

___/___/____

treatment

prophylaxis






___/___/____

___/___/____

treatment

prophylaxis






___/___/____

___/___/____

treatment

prophylaxis






___/___/____

___/___/____

treatment

prophylaxis






___/___/____

___/___/____

treatment

prophylaxis






___/___/____

___/___/____

treatment

prophylaxis






___/___/____

___/___/____

treatment

prophylaxis



F. List other CURRENT medications

Names of Other Current Medications

Dosage (mg)

Frequency

Start date





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____





___/___/____







VI. Current Medical History and Allergies



G. Please list all current medical problems including mental illnesses


Current Medical Problem List†











please list each mental health diagnosis separately





H. Please list all known drug allergies

If patient has no known drug allergies please check the following box: □ no known drug allergies

Name of medication

Reaction to medication























VII. Tobacco, Drug and Alcohol use

Is the patient a smoker?

□ yes

□ no

□ no, but past use

□ Unknown

If patient is a former smoker, how long ago did patient quit?

Years: ______

Months: _____

□ Unknown

If patient is a present or past smoker, what is the pack year smoked? Number of pack years = (packs smoked per day) × (years as a smoker)

___________

□ N/A

Does the patient use illegal drugs or abuse prescription controlled substances?

Injection drug use

□ yes

□ no

□ no, but past use

□ Unknown

Non-injection drug use

□ yes

□ no

□ no, but past use

□ Unknown

Is patient currently or has patient ever been in a substance abuse treatment program?

□ N/A

□ yes, currently in a program

□ yes, in the past

□ no

□ Unknown

If patient has ever been in a substance abuse treatment program, did patient complete the program?

□ N/A

□ yes

□ no

□ Unknown

Does the patient drink alcohol heavily?

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

□ no, but past use

□ Unknown

If patient is a former heavy drinker, how long has patient been abstinent?

□ N/A

Years: ______

Months: ______

□ Unknown

Is patient currently or has patient ever been in an alcohol abuse treatment program?

□ N/A

□ yes, currently in a program

□ yes, in the past

□ no

□ Unknown

If patient has ever been in an alcohol abuse treatment program, did they complete the program?

□ N/A

□ yes

□ no

□ Unknown




VIII. Clinic Appointment Information


Is patient new to this clinic or new to HIV care? □ yes □ no

Please list ALL appointments (medical, case management, mental health, substance abuse) scheduled for the patient in the past 24 months 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



IX. Follow-up




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


date: ____/_____/______ □ no appointment scheduled



When is patient’s first scheduled MTM appointment?


date: ____/_____/______ □ no appointment scheduled


NOTES: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




ADDITIONAL LABORATORY TEST VALUES

(use if there are more than four laboratory values in the past 12 to 24 months)


Please provide the following laboratory values for the past 24 months

Laboratory Test

Value/Date


Value/Date


Value/Date


Value/Date


CD4

(cells/ µL and %)


_____ cells/µL


_____ %


___/___/____


_____ cells/µL


_____ %


___/___/____


_____ cells/µL


_____ %


___/___/____

_____ cells/µL


_____ %


___/___/____

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


(copies/mL)

Copies/mL: __________



___/___/____

Copies/mL ___________



___/___/____

Copies/mL ___________



___/___/____

Copies/mL _____________



___/___/____


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)



________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


LDL:

(mg/dL)




________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


HDL:

(mg/dL)



________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


TG:

(mg/dL)




________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


HbA1c (only if diagnosed with diabetes):



________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


Glucose:

(mg/dL)



________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


Hemoglobin:



________



________



________



________


LFTs

(units/L)





ALT _______


AST _______


___/___/____




ALT _______


AST _______


___/___/____




ALT _______


AST _______


___/___/____




ALT _______


AST _______


___/___/____



Bilirubin

(mg/dL)




________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


Creatinine





________



___/___/____



________



___/___/____



________



___/___/____



________



___/___/____


Urinalysis




+ protein

- protein


___/___/____


+ protein

- protein


___/___/____


+ protein

- protein


___/___/____


+ protein

- protein


___/___/____


Was a basic chemistry

panel completed?

Y / N


___/___/____


Y / N


___/___/____


Y / N


___/___/____


Y / N


___/___/____


HBV DNA

(if HBV co-infected)

(copies/mL)



________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


HCV RNA

(if HCV co-infected)

(copies/mL)




________


___/___/____



________


___/___/____



________


___/___/____



________


___/___/____


Syphilis screening


negative

positive


___/___/____


negative

positive


___/___/____


negative

positive


___/___/____


negative

positive


___/___/____









































ADDITIONAL CLINIC APPOINTMENT INFORMATION

(use if 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


Initial Patient Information form Page 15 of 15


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AuthorByrd, Kathy K. (CDC/OID/NCHHSTP)
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