Quarterly Patient Information Form

Patient Project ID: __________

Staff Project ID: __________

Clinic Project ID: __________

Form Approved

OMB No: 0920-1019

Exp. Date: 08/31/2018

Integrating Community Pharmacists and Clinical Sites

for Patient-Centered HIV Care

Attachment 7a 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 (0920-1019)

_________________________________________________________________________________________

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