Initial Patient Information Form

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)

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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:

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_{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