Data Items Abstracted from the Participant's Medical Chart by Study Personnel

4/16/2019

99991002: Anal_Cerv PAP_Bx

99991002: Anal_Cerv PAP_Bx
*

Collection Date

Comment

yyyy-mm-dd

Anal Biopsy

A BX HPV

Units

LLN

ULN

Comment

A BX AIN1

Units

LLN

ULN

Comment

A BX AIN2

Units

LLN

ULN

Comment

A BX AIN3

Units

LLN

ULN

Comment

A BX CIS

Units

LLN

ULN

Comment

A BX Norm

Units

LLN

ULN

Comment

A BX Other

Units

LLN

ULN

Comment

A BX Atypia

Units

LLN

ULN

Comment

A BX Cancer

Units

LLN

ULN

Comment

Anal Pap Smear

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99991002: Anal_Cerv PAP_Bx

A PAP
ASCUS

Units

LLN

ULN

Comment

A PAP HGSIL

Units

LLN

ULN

Comment

A PAP LGSIL

Units

LLN

ULN

Comment

A PAP Other

Units

LLN

ULN

Comment

A PAP
Cancer

Units

LLN

ULN

Comment

A PAP
Normal

Units

LLN

ULN

Comment

C BX CIN1

Units

LLN

ULN

Comment

C BX CIN2

Units

LLN

ULN

Comment

C BX CIN3

Units

LLN

ULN

Comment

C BX CIS

Units

LLN

ULN

Comment

C BX HPV

Units

LLN

ULN

Comment

C BX Norm

Units

LLN

ULN

Comment

Cervical Biopsy

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4/16/2019

99991002: Anal_Cerv PAP_Bx

C BX Other

Units

LLN

ULN

Comment

C BX Atypia

Units

LLN

ULN

Comment

C BX Cancer

Units

LLN

ULN

Comment

Cervical Pap Smear

C PAP
ASCUS

Units

LLN

ULN

Comment

C PAP HGSIL

Units

LLN

ULN

Comment

C PAP LGSIL

Units

LLN

ULN

Comment

C PAP Other

Units

LLN

ULN

Comment

C PAP
Cancer

Units

LLN

ULN

Comment

C PAP

Units

LLN

ULN

Comment

HPV Cervix

Units

LLN

ULN

Comment

HPV Vagina

Units

LLN

ULN

Comment

Normal

HPV

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4/16/2019

99991002: Anal_Cerv PAP_Bx

HPV Anal

Units

LLN

ULN

Comment

HPVanIDcrn

Units

LLN

ULN

Comment

V BX CIS

Units

LLN

ULN

Comment

V BX HPV

Units

LLN

ULN

Comment

V BX Norm

Units

LLN

ULN

Comment

V BX Other

Units

LLN

ULN

Comment

V BX VAIN1

Units

LLN

ULN

Comment

V BX VAIN2

Units

LLN

ULN

Comment

V BX VAIN3

Units

LLN

ULN

Comment

V BX Atypia

Units

LLN

ULN

Comment

V BX Cancer

Units

LLN

ULN

Comment

V PAP

Units

LLN

ULN

Comment

Vaginal Biopsy

ASCUS

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4/16/2019

99991002: Anal_Cerv PAP_Bx

V PAP HGSIL

Units

LLN

ULN

Comment

V PAP LGSIL

Units

LLN

ULN

Comment

V PAP Other

Units

LLN

ULN

Comment

V PAP

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Leep

Units

LLN

ULN

Comment

Cervical Pap

Units

LLN

ULN

Comment

Anal Pap

Units

LLN

ULN

Comment

Cancer

V PAP
Normal

Pap Procedures

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4/16/2019

99991002: BIA

99991002: BIA
*

Date

Comment

yyyy-mm-dd

BIA

BIA

Units

LLN

ULN

Comment

Body Fat

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

in lbs

Total
Weight
in lbs

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4/16/2019

99991002: Cancer

99991002: Cancer
*

Date

Comment

yyyy-mm-dd

Cancer Screening

Beta 2 Mic

Units

LLN

ULN

Comment

PSA

Units

LLN

ULN

Comment

AFP

Units

LLN

ULN

Comment

https://cerner.eu.openclinica.io/OpenClinica/EnketoFormServlet?formLayoutId=11&studyEventId=98&eventCrfId=0&originatingPage=ViewStudySubje…

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4/16/2019

99991002: Cultures

99991002: Cultures
*

Collection date

Comment

yyyy-mm-dd

Cultures

Blood

Units

LLN

ULN

Comment

Bone
Culture

Units

LLN

ULN

Comment

Other
Culture

Units

LLN

ULN

Comment

Sputum
Culture

Units

LLN

ULN

Comment

Stool
Culture

Units

LLN

ULN

Comment

Urine
Culture

Units

LLN

ULN

Comment

Wound
Culture

Units

LLN

ULN

Comment

Culture

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99991002: Demographics

99991002: Demographics
Demography: General 1

Consent obtained:
No

*
Yes

Consent date:

yyyy-mm-dd

Extract:
No

Does patient receive primary care at
this site:

Yes

No

Yes
*

Date of birth:

yyyy-mm-dd

Gender at birth:
Female

Male

*
Unknown

Race:

Current gender:
Female

*

Male

*
Unknown

Ethnicity:

*

*

Patient Status:

Employment status:

Education level:

Active/Inactive Dates:

Date patient became active:

yyyy-mm-dd

*

Date patient became inactive:

yyyy-mm-dd

Demography: General 2
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4/16/2019

Primary insurance:

99991002: Demographics

*

Secondary insurance:

Normal/baseline height
in inches

Description for other:

Description for other:

*

Normal/baseline weight

*

in pounds

Lowest ever adult weight
in pounds

Demography for Females Only

> Number of Pregnancies

> Number of Births

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4/16/2019

99991002: Diagnosis

99991002: Diagnosis
Diagnosis:
*

Start date:

yyyy-mm-dd

End date:

yyyy-mm-dd

Diagnosis Details

Diagnosis:

*

Diagnosis description
Type to search:

Additional diagnosis description:

Comment:

Hospitalized:

*

Presumptive/Verified:

*

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4/16/2019

99991002: Disease Testing

99991002: Disease Testing
*

Collection date

Comment

yyyy-mm-dd

Disease Testing

Influenza A

Units

LLN

ULN

Comment

Influenza B
Culture

Units

LLN

ULN

Comment

Quidel FLU

Units

LLN

ULN

Comment

Other FLU

Units

LLN

ULN

Comment

Rapid Strep

Units

LLN

ULN

Comment

PPD

Units

LLN

ULN

Comment

Monospot

Units

LLN

ULN

Comment

CryptoStol

Units

LLN

ULN

Comment

O&P

Units

LLN

ULN

Comment

Culture

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4/16/2019

99991002: Disease Testing

Qnt TB Gold

Units

LLN

ULN

Comment

H. Pylori

Units

LLN

ULN

Comment

Rubella

Units

LLN

ULN

Comment

T-Spot TB
Test

Units

LLN

ULN

Comment

https://cerner.eu.openclinica.io/OpenClinica/EnketoFormServlet?formLayoutId=13&studyEventId=100&eventCrfId=0&originatingPage=ViewStudySubj…

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4/16/2019

99991002: Drug Levels

99991002: Drug Levels
*

Collection date

Comment

yyyy-mm-dd

Drug levels

VitD 25 Hy

Units

LLN

ULN

Comment

VitD 1, 25Di

Units

LLN

ULN

Comment

Lithium

Units

LLN

ULN

Comment

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4/16/2019

99991002: Encounter

99991002: Encounter
Date

*

Encounter Type

*

yyyy-mm-dd

Current Primary Payer

*

Description for Other

Vitals

Systolic Blood Pressure

*

Diastolic Blood Pressure

mmHg

mmHg

Heart Rate

Respiratory Rate

beats/min

breaths/min

Temperature

*

Current Weight

(in degrees Fahrenheit)

(in lbs)

Height

Comments

*

*

(in inches)

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4/16/2019

99991002: Endo_Rheum

99991002: Endo_Rheum
*

Collection date

Comment

yyyy-mm-dd

Endocrinology/Rheumatology

TSH

Units

LLN

ULN

Comment

T-3, total

Units

LLN

ULN

Comment

T-3, uptake

Units

LLN

ULN

Comment

T-4, free

Units

LLN

ULN

Comment

T-4, total

Units

LLN

ULN

Comment

T-7, FTI

Units

LLN

ULN

Comment

Test Total

Units

LLN

ULN

Comment

FREE Test

Units

LLN

ULN

Comment

Free Test %

Units

LLN

ULN

Comment

TESTO F/WB

Units

LLN

ULN

Comment

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4/16/2019

99991002: Endo_Rheum

FSH

Units

LLN

ULN

Comment

LH

Units

LLN

ULN

Comment

Prolactin

Units

LLN

ULN

Comment

PTH

Units

LLN

ULN

Comment

Cortisol, M

Units

LLN

ULN

Comment

Cortisol, F

Units

LLN

ULN

Comment

Estradiol

Units

LLN

ULN

Comment

https://cerner.eu.openclinica.io/OpenClinica/EnketoFormServlet?formLayoutId=15&studyEventId=103&eventCrfId=0&originatingPage=ViewStudySubj…

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4/16/2019

99991002: General Blood

99991002: General Blood
*

Collection Date:

Comment:

yyyy-mm-dd

Fasting Lab

Units

LLN

ULN

Comment

WBC

Units

LLN

ULN

Comment

RBC

Units

LLN

ULN

Comment

Hgb

Units

LLN

ULN

Comment

Hematocrit

Units

LLN

ULN

Comment

MCV

Units

LLN

ULN

Comment

RDW

Units

LLN

ULN

Comment

Platelets

Units

LLN

ULN

Comment

MPV

Units

LLN

ULN

Comment

Neut %

Units

LLN

ULN

Comment

CBC

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99991002: General Blood

Lymph %

Units

LLN

ULN

Comment

Mono %

Units

LLN

ULN

Comment

Eosinoph %

Units

LLN

ULN

Comment

Bands %

Units

LLN

ULN

Comment

Neutrophil

Units

LLN

ULN

Comment

Lymphocyte

Units

LLN

ULN

Comment

Sodium

Units

LLN

ULN

Comment

Potassium

Units

LLN

ULN

Comment

Chloride

Units

LLN

ULN

Comment

Bicarb (CO2)

Units

LLN

ULN

Comment

BUN

Units

LLN

ULN

Comment

Creat

Units

LLN

ULN

Comment

GFR

Units

LLN

ULN

Comment

Chemistry

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4/16/2019

99991002: General Blood

Glucose

Units

LLN

ULN

Comment

Calcium

Units

LLN

ULN

Comment

Total Prot

Units

LLN

ULN

Comment

Albumin

Units

LLN

ULN

Comment

Globulin

Units

LLN

ULN

Comment

A/G Ratio

Units

LLN

ULN

Comment

Bilirubin

Units

LLN

ULN

Comment

Bili Dir

Units

LLN

ULN

Comment

Bili Ind

Units

LLN

ULN

Comment

Alka. Phos

Units

LLN

ULN

Comment

AST (SGOT)

Units

LLN

ULN

Comment

ALT (SGPT)

Units

LLN

ULN

Comment

LDH

Units

LLN

ULN

Comment

Total

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4/16/2019

99991002: General Blood

GGT

Units

LLN

ULN

Comment

CK/CPK

Units

LLN

ULN

Comment

Mg

Units

LLN

ULN

Comment

Phos

Units

LLN

ULN

Comment

Uric Acid

Units

LLN

ULN

Comment

Amylase

Units

LLN

ULN

Comment

Lipase

Units

LLN

ULN

Comment

Chol

Units

LLN

ULN

Comment

HDL Chol

Units

LLN

ULN

Comment

LDL Chol

Units

LLN

ULN

Comment

VLDL Chol

Units

LLN

ULN

Comment

Risk Ratio

Units

LLN

ULN

Comment

Trigly

Units

LLN

ULN

Comment

Lipids

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99991002: General Blood

Coagulation

INR

Units

LLN

ULN

Comment

PT

Units

LLN

ULN

Comment

PTT, APTT

Units

LLN

ULN

Comment

TCT

Units

LLN

ULN

Comment

Fibrinogen

Units

LLN

ULN

Comment

Insulin/Glucose Control

Insul-Fast

Units

LLN

ULN

Comment

HGB A1c

Units

LLN

ULN

Comment

Iron

Units

LLN

ULN

Comment

TIBC

Units

LLN

ULN

Comment

Retic Cnt

Units

LLN

ULN

Comment

Folate

Units

LLN

ULN

Comment

Ferritin

Units

LLN

ULN

Comment

Iron

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Transferin

99991002: General Blood

Units

LLN

ULN

Comment

ESR

Units

LLN

ULN

Comment

EPO

Units

LLN

ULN

Comment

Leptin

Units

LLN

ULN

Comment

Aldolase

Units

LLN

ULN

Comment

Adiponectin

Units

LLN

ULN

Comment

Troponin I

Units

LLN

ULN

Comment

Troponin T

Units

LLN

ULN

Comment

CRP

Units

LLN

ULN

Comment

Cystatin C

Units

LLN

ULN

Comment

hCG, Quant

Units

LLN

ULN

Comment

Carnit-Tot

Units

LLN

ULN

Comment

Carnit-Fre

Units

LLN

ULN

Comment

Other Testing

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99991002: General Blood

LacticAcid

Units

LLN

ULN

Comment

Cryoglob

Units

LLN

ULN

Comment

B-12

Units

LLN

ULN

Comment

G6PD

Units

LLN

ULN

Comment

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99991002: Genotype

99991002: Genotype
*

Collection date

yyyy-mm-dd

Adequate specimen

*

Yes

No
*

Vendor

Other vendor

Clades other than B

Comment

Protease Inhibitor

PI Mutations

8

10

11

13

15

16

20

23

24

30

32

33

34

35

36

37

39

41

42

43

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99991002: Genotype

46

47

48

50

53

54

57

58

60

62

63

64

65

69

71

73

74

76

77

79

81

82

83

84

85

88

89

90

91

93

Protease Inhibitors

SQV

NFV

APV

IDV

RTV

LPV/r

ATV

DRV

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99991002: Genotype

TPV

fAPV

Comment

Nucleoside RT Inhibitor

NRTI Mutations

14

41

43

44

62

65

67

69

69in

70

74

75

77

98

102

115

116

118

135

151

162

169

184

189

200

203

207

208

210

211

214

215

219

221

228

238

277

286

293

312

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99991002: Genotype

333

351

386

Nucleoside RT Inhibitors

DDI

D4T

3TC

ZDV

ABC

DDC

FTC

TDF

Comment

Non-Nucleoside RT Inhibitor

NNRTI Mutations

43

90

96

98

100

101

102

103

105

106

108

125

135

138

179

181

188

189

190

203

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99991002: Genotype

208

211

214

221

225

227

228

230

236

238

245

312

318

333

Non-nucleoside RT Inhibitors

NVP

DLV

EFV

ETR

RLPV

Comment

EI/INSTI

Other Inhibitor Mutations

11

24

33

36

37

38

39

40

42

43

44

45

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99991002: Genotype

66

73

74

75

92

97

102

115

116

121

122

126

130

133

136

138

140

143

147

148

155

157

169

192

263

278

Other Inhibitors

T20

RTG

MVC

DTG

ELVG

Comment

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99991002: HCV Hepatic Fibrosis

99991002: HCV Hepatic Fibrosis
*

Collection date

Comment

yyyy-mm-dd

HCV Hepatic Fibrosis

Fibrosis Stage

Necroinflammatory Activity Grade

HCV Hepatic Fibrosis Labs

Fibrosis
Score

Units

LLN

ULN

Comment

Necroinfla
mmatory
Activity
Score

Units

LLN

ULN

Comment

Alanine
Aminotrans
ferase

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

(ALT/SGPT)

A2 Macroglobu
lin

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99991002: HCV Hepatic Fibrosis

Apolipoprot
ein A1

Units

LLN

ULN

Comment

Bilirubin

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Total

Y-Glutamyl
Transferase
(GGT)

Haptoglobin

Fibroscan

Fibroscan
Result

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99991002: HIV labs

99991002: HIV labs
Collection date

Comment

yyyy-mm-dd

HIV

CD4

Units

LLN

ULN

Comment

CD4%

Units

LLN

ULN

Comment

CD8

Units

LLN

ULN

Comment

CD8%

Units

LLN

ULN

Comment

CD4/CD8 HS

Units

LLN

ULN

Comment

rtPCR20

Units

LLN

ULN

Comment

rtPCR25

Units

LLN

ULN

Comment

rtPCR40

Units

LLN

ULN

Comment

rtPCR50

Units

LLN

ULN

Comment

rtPCR100

Units

LLN

ULN

Comment

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99991002: HIV labs

rtPCR200

Units

LLN

ULN

Comment

rtPCR400

Units

LLN

ULN

Comment

rtPCR500

Units

LLN

ULN

Comment

rtPCR1000

Units

LLN

ULN

Comment

rtPCROthr

Units

LLN

ULN

Comment

bDNA

Units

LLN

ULN

Comment

rtPCR48

Units

LLN

ULN

Comment

HIV geno

Units

LLN

ULN

Comment

HIV pheno

Units

LLN

ULN

Comment

HIV trofile

Units

LLN

ULN

Comment

HIV Elisa

Units

LLN

ULN

Comment

Western
Blot

Units

LLN

ULN

Comment

HIV P24 An

Units

LLN

ULN

Comment

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99991002: HIV labs

HIV-2

Units

LLN

ULN

Comment

HIV Rapid

Units

LLN

ULN

Comment

HLA

Units

LLN

ULN

Comment

HLA-B*5701

Units

LLN

ULN

Comment

HIV Confirmatory Panel

AG AB COMB IMMUNOASSAY
Nonreactive

Reactive

AB DIFF IMMUNOASSAY
HIV-1 reactive and HIV-2 nonreactive
HIV-1 and HIV-2 reactive
HIV-1 nonreactive and HIV-2 reactive
Indeterminate
Nonreactive

HIV 1 RNA ASSAY
RNA detected

RNA not detected

Result not available

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99991002: Hospital History

99991002: Hospital History
Length of Stay
*

Admission Date:

yyyy-mm-dd

Discharge Date:

yyyy-mm-dd

Reason for Hospitalization

Reason 1:

*

Reason 1 description:
Type to search:

Additional Detail:
Required if an "Other" or "Specify" code is selected

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99991002: ID Serology

99991002: ID Serology
*

Collection date

Comment

yyyy-mm-dd

Hepatitis A

HepA AB

Units

LLN

ULN

Comment

HepA
AblGM

Units

LLN

ULN

Comment

HA AB IGG

Units

LLN

ULN

Comment

Hep A PCR

Units

LLN

ULN

Comment

HB Core AB

Units

LLN

ULN

Comment

Hep B Core

Units

LLN

ULN

Comment

HB Surf AG

Units

LLN

ULN

Comment

HBcAB IGG

Units

LLN

ULN

Comment

HBcAB IGM

Units

LLN

ULN

Comment

Hepatitis B

Ag

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99991002: ID Serology

HB Surf AB

Units

LLN

ULN

Comment

HBSAB, QT

Units

LLN

ULN

Comment

HepBEAb

Units

LLN

ULN

Comment

HepBEAg

Units

LLN

ULN

Comment

HepB DNA

Units

LLN

ULN

Comment

HBV

Units

LLN

ULN

Comment

HCV
Antibody

Units

LLN

ULN

Comment

HCV RNA
Quan PCR
VL

Units

LLN

ULN

Comment

HCV
Genotype

Units

LLN

ULN

Comment

HCV b-DNA

Units

LLN

ULN

Comment

HCV RNA
Qualitative

Units

LLN

ULN

Comment

VLQUAL

Hepatitis C

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99991002: ID Serology

Other Hepatitis

Hep D AB

Units

LLN

ULN

Comment

Epstein Bar Virus (EBV)

EBV

Units

LLN

ULN

Comment

EVB VCAIGM

Units

LLN

ULN

Comment

EBV VCAIGG

Units

LLN

ULN

Comment

EBV EA IGA

Units

LLN

ULN

Comment

EBV EA IGG

Units

LLN

ULN

Comment

EBV NA IGG

Units

LLN

ULN

Comment

EBV NA IGM

Units

LLN

ULN

Comment

Herpes 1
IGG

Units

LLN

ULN

Comment

Herpes 1

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Herpes (HSV)

IGM

Herpes 2
IGG

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99991002: ID Serology

Herpes 2
IGM

Units

LLN

ULN

Comment

Herpes 1 AB

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Herpes 2 AB
Quant

Units

LLN

ULN

Comment

Herpes 2
PCR Quant

Units

LLN

ULN

Comment

Quant

Herpes 1
PCR Quant

Cytomegalovirus (CMV)

CMV IGG

Units

LLN

ULN

Comment

CMV IGM

Units

LLN

ULN

Comment

CMV PCR

Units

LLN

ULN

Comment

CMV AB

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Toxoplasmosis

Toxo IGG

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Toxo IGM

99991002: ID Serology

Units

LLN

ULN

Comment

Crypto AB

Units

LLN

ULN

Comment

Crypto AG

Units

LLN

ULN

Comment

Myco IGG

Units

LLN

ULN

Comment

Myco IGM

Units

LLN

ULN

Comment

Histo AG

Units

LLN

ULN

Comment

Lyme AB

Units

LLN

ULN

Comment

VZV Ab

Units

LLN

ULN

Comment

MRSA

Units

LLN

ULN

Comment

Parv B19
DNA

Units

LLN

ULN

Comment

Legionella

Units

LLN

ULN

Comment

Cryptococcosis

Other Serology

screen

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99991002: ID Serology

AFB

Units

LLN

ULN

Comment

Interleukin
28B

Units

LLN

ULN

Comment

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99991002: Imaging

99991002: Imaging
*

Date

Comment

yyyy-mm-dd

Imaging

X-Ray

Units

LLN

ULN

Comment

MRI

Units

LLN

ULN

Comment

CAT Scan

Units

LLN

ULN

Comment

Ultrasound

Units

LLN

ULN

Comment

Galium Scan

Units

LLN

ULN

Comment

IVP

Units

LLN

ULN

Comment

Other
Radiology

Units

LLN

ULN

Comment

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99991002: Mortality

99991002: Mortality
Mortality
*

Date of Death:

yyyy-mm-dd

Primary cause of death

Primary cause of death
1:

*

Primary cause of death 1 description:
Type to search:

Primary cause of death
2:

Primary cause of death 2 description:

Primary cause of death
3:

Primary cause of death 3 description:

Primary cause of death
4:

Primary cause of death 4 description:

Type to search:

Type to search:

Type to search:

Other cause:

Secondary cause of death

Secondary cause of

Secondary cause of death 1 description:

death 1:

Type to search:

Secondary cause of
death 2:

Secondary cause of death 2 description:
Type to search:

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99991002: Mortality

Secondary cause of
death 3:

Secondary cause of death 3 description:

Secondary cause of

Secondary cause of death 4 description:

death 4:

Type to search:

Type to search:

Other secondary cause:

Source of primary and secondary cause of death information

Clinic chart is source of information?
No

Yes

Abstracted summary of hospital record is source of information?
No

Yes

Death certificate is a source of information?
No

Yes

HIV clinician is a source of information?
No

Yes

Other source:

Other medical conditions occurring at the time of death

Diagnosis existing at

Diagnosis existing at time of death 1 description:

time of death 1:

Type to search:

Diagnosis existing at
time of death 2:

Diagnosis existing at time of death 2 description:

Diagnosis existing at
time of death 3:

Diagnosis existing at time of death 3 description:

Type to search:

Type to search:

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99991002: Mortality

Diagnosis existing at
time of death 4:

Diagnosis existing at time of death 4 description:

Diagnosis existing at
time of death 5:

Diagnosis existing at time of death 5 description:

Diagnosis existing at
time of death 6:

Diagnosis existing at time of death 6 description:

Type to search:

Type to search:

Type to search:

Source of other medical information

Clinic chart is a source of information?
No

Yes

Abstracted summary of hospital record is source of information?
No

Yes

Death certificate is a source of information?
No

Yes

HIV clinician is a source of information
No

Yes

Other source:

Hospitalization at the time of death

Was the patient hospitalized at time of death?
No

Yes

*

Unkn

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99991002: Other Biopsy

99991002: Other Biopsy
*

Collection date

Comment

yyyy-mm-dd

Other Biopsy

Liver Biopsy

Units

LLN

ULN

Comment

Liver Portal

Units

LLN

ULN

Comment

Liver
Lobular

Units

LLN

ULN

Comment

Liver
Fibrosis

Units

LLN

ULN

Comment

LivPnecros

Units

LLN

ULN

Comment

Biopsy

Units

LLN

ULN

Comment

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99991002: Phenotype

99991002: Phenotype
*

Collection date

yyyy-mm-dd

Adequate specimen
Yes

*
No

Replication capacity
%

Tropism
Mixed/Dual

R5

X4
*

Vendor

Other vendor

Comment

Protease Inhibitor

SQV

SQV fold change

NFV

APV

SQV/r

SQV/r fold chnge

NFV fold change

APV fold change

APV/r

APV/r fold
change

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IDV

99991002: Phenotype

IDV fold change

IDV/r

RTV

RTV fold change

LPV/r

LPV/r fold change

ATV

ATV fold change

DRV/r

ATV/r

IDV/r fold
change

ATV/r fold
change

DRV/r fold change

TPV

TPV fold change

TPV/r

TPV/r fold
change

fAPV

fAPV fold change

fAPV/r

fAPV/r fold
change

Comment

Nucleoside RT Inhibitor

DDI

DDI fold change

D4T

D4T fold change

3TC

3TC fold change

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99991002: Phenotype

ZDV

ZDV fold change

ABC

ABC fold change

DDC

DDC fold change

FTC

FTC fold change

TDF

TDF fold change

Comment

Non-nucleoside RT Inhibitor

NVP

NVP fold change

DLV

DLV fold change

EFV

EFV fold change

ETR

ETR fold change

RLPV

RLPV fold change

Comment

Other Inhibitor

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99991002: Phenotype

T20

T20 fold change

RTG

RTG fold change

MVC

MVC fold change

DTG

DTG fold change

ELVG

ELVG fold change

Comment

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99991002: Procedures

99991002: Procedures
*

Procedure date

Comment

yyyy-mm-dd

Procedures

Abd CT

Units

LLN

ULN

Comment

Anoscopy

Units

LLN

ULN

Comment

Atrial Flu

Units

LLN

ULN

Comment

Bronchosco
pe

Units

LLN

ULN

Comment

Carotid
Ultrasound

Units

LLN

ULN

Comment

Colonoscop
y

Units

LLN

ULN

Comment

Colposcopy

Units

LLN

ULN

Comment

CorcalMSCT

Units

LLN

ULN

Comment

Cytoscopy

Units

LLN

ULN

Comment

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99991002: Procedures

DEXA body

Units

LLN

ULN

Comment

DEXA hip

Units

LLN

ULN

Comment

Dexa L
spine

Units

LLN

ULN

Comment

Echocardiog
ram

Units

LLN

ULN

Comment

EEG

Units

LLN

ULN

Comment

Ejection
Fracture

Units

LLN

ULN

Comment

EKG

Units

LLN

ULN

Comment

EMG

Units

LLN

ULN

Comment

Endoscopy

Units

LLN

ULN

Comment

ERCP

Units

LLN

ULN

Comment

Eye Exam

Units

LLN

ULN

Comment

FOB

Units

LLN

ULN

Comment

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99991002: Procedures

Glucose 1

Units

LLN

ULN

Comment

Glucose 2

Units

LLN

ULN

Comment

Glucose 3

Units

LLN

ULN

Comment

Glucose F

Units

LLN

ULN

Comment

Holter

Units

LLN

ULN

Comment

Lumbar
Puncture

Units

LLN

ULN

Comment

Mammogra
m

Units

LLN

ULN

Comment

Manual
Pros

Units

LLN

ULN

Comment

Nuclear
Medicine

Units

LLN

ULN

Comment

PFT

Units

LLN

ULN

Comment

Sigmoidosc
opy

Units

LLN

ULN

Comment

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99991002: Procedures

Stress Test

Units

LLN

ULN

Comment

Vascular

Units

LLN

ULN

Comment

Study

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99991002: Prophylaxis

99991002: Prophylaxis
*

Date prophylaxis started:

yyyy-mm-dd

Date prophylaxis ended:

yyyy-mm-dd

Prophylaxis Details

Reason for
discontinuation:

Reason for discontinuation description:
Type to search:

Prophylaxis type:

*

drug

Specific prophylaxis:

vaccine
*

Specific prophylaxis description

Additional description:

Date prophylaxis expires (if applicable):

yyyy-mm-dd

Sequence/booster: (if applicable)

*

Dose:

Target Disease

Target disease 1:

*

Target disease 1 description:
Type to search:

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Target disease 2:

99991002: Prophylaxis

Target disease 2 description:
Type to search:

Target disease 3:

Target disease 3 description:
Type to search:

Description of other target disease:

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99991002: Referrals_Misc

99991002: Referrals_Misc
*

Date

Comment

yyyy-mm-dd

Referrals and Miscellaneous

Circumcisio

Units

LLN

ULN

Comment

Low Weight

Units

LLN

ULN

Comment

Depr by HIV

Units

LLN

ULN

Comment

n

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99991002: STD

99991002: STD
*

Collection date

Comment

yyyy-mm-dd

Sexually Transmitted Infections
Gonorrhea

GC Oral

Units

LLN

ULN

Comment

GC Urine

Units

LLN

ULN

Comment

GC Urethral

Units

LLN

ULN

Comment

GC Cervical

Units

LLN

ULN

Comment

GC Rectal

Units

LLN

ULN

Comment

GC (O, APTI)

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Obsolete. Do not use.

GC (R,APTI)
Obsolete. Do not use.

GC (U, APTI)
Obsolete. Do not use.

GC urthNAT

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99991002: STD

Chlamydia

CT Oral

Units

LLN

ULN

Comment

CT Urine

Units

LLN

ULN

Comment

CT Urethral

Units

LLN

ULN

Comment

CT Cervical

Units

LLN

ULN

Comment

CT Rectal

Units

LLN

ULN

Comment

CT (O,APTI)

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Obsolete. Do not use.

CT (R, APTI)
Obsolete. Do not use.

CT (U, APTI)
Obsolete. Do not use.

CT urthNAT

Syphilis

Syphilis RPR
Qualitative

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99991002: STD

Syphilis RPR
Quantitativ
e

Units

LLN

ULN

Comment

VDRL

Units

LLN

ULN

Comment

FTA-ABS

Units

LLN

ULN

Comment

Units

LLN

ULN

Comment

Trich Urine

Units

LLN

ULN

Comment

Trich
Vaginal

Units

LLN

ULN

Comment

Fluorescent Treponemal
antibody absorption

TP-PA
Treponema pallidum
particle agglutination
assay

Trichomonas

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99991002: Surveys_Forms

99991002: Surveys_Forms
*

Collection date

Comment

yyyy-mm-dd

Surveys and Forms

ACASI

Units

LLN

ULN

Comment

Neuro
Cognitive
Test

Units

LLN

ULN

Comment

Lipo Exam

Units

LLN

ULN

Comment

Safe Sex
Counseling

Units

LLN

ULN

Comment

Question

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99991002: Treatment

99991002: Treatment
*

Start date:

yyyy-mm-dd

End date:

yyyy-mm-dd

Treatment Details
*

Treatment:

Treatment description:
Type to search:

Additional description:

*

Strength:

*

Units:

*

Quantity:

Other units:

Other quantity:

*

Frequency:

*

Route:

*

Form:

Other instructions:

Adherence

Was this treatment prescribed as part of a clinical trial?
No

Yes

Was this a blinded or placebo clinical trial?
No

Yes

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99991002: Treatment

What was the adherence to this drug?
No doses missed since last report

Doses missed

Doses missed:

Not addressed

Doses missed during:

Discontinuation

Reason for
discontinuation 1:

Reason for discontinuation 1 description:

Reason for
discontinuation 2:

Reason for discontinuation 2 description:

Reason for
discontinuation 3:

Reason for discontinuation 3 description:

Reason for
discontinuation 4:

Reason for discontinuation 4 description:

Reason for
discontinuation 5:

Reason for discontinuation 5 description:

Type to search:

Type to search:

Type to search:

Type to search:

Type to search:

Diagnosis

Diagnosis 1:

*

Diagnosis 1 description:
Type to search:

Additional description 1:

Diagnosis 2:

Diagnosis 2 description:
Type to search:

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99991002: Treatment

Additional description 2:

Diagnosis 3:

Diagnosis 3 description:
Type to search:

Additional description 3:

Comment:

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99991002: Trofile

99991002: Trofile
Trofile
*

Collection date:

yyyy-mm-dd

Adequate specimen:
No

*
Yes

CXCR4(X4):
Detected

Not Detected

MVC Activity Anticipated (CCR5 antagonist anticipated):
No

Yes

Tropotype result:

Options:
Tropism/Trofile

Tropism Viral DNA/Trofile DNA

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99991002: Urine

99991002: Urine
*

Collection date

Comment

yyyy-mm-dd

Urine Results

Specific

Units

LLN

ULN

Comment

Urine pH

Units

LLN

ULN

Comment

Urine
Glucose

Units

LLN

ULN

Comment

Urine
Protein

Units

LLN

ULN

Comment

Urine
Ketone

Units

LLN

ULN

Comment

Urine

Units

LLN

ULN

Comment

Urobil -/+

Units

LLN

ULN

Comment

Urine
Leukocytes

Units

LLN

ULN

Comment

Gravity

bilinogn

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99991002: Urine

Urine Blood

Units

LLN

ULN

Comment

Urine
Nitrite

Units

LLN

ULN

Comment

Urine
Bilirubin

Units

LLN

ULN

Comment

Urine
Microalbum

Units

LLN

ULN

Comment

Urine
Creatinine

Units

LLN

ULN

Comment

Micr/Creat

Units

LLN

ULN

Comment

Urine Micro

Units

LLN

ULN

Comment

Cort/Urine

Units

LLN

ULN

Comment

Preg Test

Units

LLN

ULN

Comment

in

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