Appendix A: Short Intake Form for Persons with HIV Who Are Seeking Care

Updated Reviewed

Appendix A: Short Intake Form for Persons with HIV Who Are Seeking Care
CONTACT INFORMATION
Patient Name
Location
Phone number
Email address		  
PROVIDERS
Name, location, phone number, pager number, and email address of the primary HIV care provider/clinic and research staff (if the patient is participating in a research study, such as a clinical trial)  
Name, location, and phone number of the pharmacy where the patient obtained medications  
MEDICAL HISTORY
Pertinent past medical history (including history of opportunistic infections, malignancies, and other medical conditions such as hypertension and diabetes mellitus)  
History of hepatitis B or hepatitis C coinfection (according to the patient) Hepatitis B: ____ yes ____ no
Hepatitis C: ____ yes ____ no
Latest known CD4 cell count/percentage and HIV viral load, with approximate dates for when each was obtained  
TREATMENT
Antiretroviral drugs, including dosing information (e.g., dose, number of pills, dosing frequency)

Images of Food and Drug Administration (FDA)-approved antiretroviral medications can be found at go.usa.gov/xPgrP		  
Medications for treatment of opportunistic infections

 		  
Medications for prevention of opportunistic infections

 		  
Any investigational medications
(if the patient is participating in a clinical trial, obtain information about the clinical trial site and contact information, if available)
 		  
Other medications

 		  
DRUG ALLERGIES/INTOLERANCE
History of drug allergies and the types of reactions experienced

Pay special attention to allergies to abacavir or drugs used for the treatment or prevention of opportunistic infections, such as trimethoprim-sulfamethoxazole. Patients who have had positive genetic tests for the HLA-B* 5701 allele should not be given abacavir (Ziagen™) or fixed-dose combinations containing abacavir (Epzicom™, Trizivir™, or Triumeq™).		  
History of intolerance to antiretroviral medications and other medications
 		  

 

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