Quarterly Patient Information Form

Entry system is password protected.

Patient, staff, and clinic IDs are entered once instead of every page

Note: Page 2 of 20 of QPIF is for clinic use only and hence not incorporated into the entry system.

QPIF Page 3 of 20

QPIF Page 4 of 20: Patient Information

QPIF Page 4-5 of 20: Patient Lab Information

QPIF Page 5-7 of 20: B. Please update laboratory …
These are broken down into blocks due to space issues on the web page.

QPIF Page 7 of 20: C. Please provide … viral hepatitis …

QPIF Page 7-8 of 20: II. Medication Updates

QPIF Page 8-9 of 20: A2

QPIF Page 9 of 20: A3
Due to space, entries wrap around to the next block. The numbers, 1, 2,…,6 indicate which medication goes
with which reason.

QPIF Page 9-10 of 20: B1 and B2

QPIF Page 10-11 of 20: B3
Due to space, entries wrap around to the next block. The numbers, 1, 2,…,6 indicate which medication goes
with which reason.

QPIF Page 11-12 of 20: III. Medical History and Allergies

QPIF Page 12-13 of 20: IV. Tobacco, Drug and Alcohol use

QPIF Page 13 of 20: V. Immunization History

QPIF Page 13-14 of 20: VI. Clinic Appointment Information

QPIF Page 14-15 of 20: VII. MTM
Due to space, entries wrap around to the next block. The numbers, 1, 2,…,5 indicate entries.

QPIF Page 15-16 of 20: VII. Follow-up
Section VII is used twice on the paper form. The system reflects this probable typo.

QPIF Page 16-19 of 20: Additional Laboratory test values

QPIF Page 19-20 of 20: Additional clinic appointment information

Miscellaneous
At the very end, there is a comment box to indicate any unexpected events during the entry.
Once the Submit button is clicked, the user is given an option to download the entered form as a PDF.