Appendix A: Sample Short Intake Form for People With HIV Who Are Seeking Care
| Contact Information | |
|---|---|
Legal name Additional name (if different from legal name) Location Phone number Email address Emergency contact information | |
| Providers, Prescription Drug Coverage, and Access to Electronic Health Information | |
Name, location, phone number, pager number, and email address of the primary HIV care provider/clinic and research staff (if the person is participating in a clinical trial) Access to patient portal for health care system | _______ yes ____ no |
Name, location, and phone number of the pharmacy where the person obtained medications Access to patient portal for pharmacy | _______ yes ____ no |
| Name and phone number for primary and any secondary prescription drug coverage (e.g., commercial insurance, employer-sponsored insurance, Medicare Part D, Medicare Advantage, ADAP, VA) | |
| Medical History | |
| Currently pregnant | ____ yes ____ no |
| Pertinent past medical history (including history of OIs, malignancies, and other medical conditions, such as hypertension and diabetes mellitus) | |
| History of HBV or HCV coinfection (according to the person with HIV) | HBV: ____ yes ____ no HCV: ____ yes ____ no |
| Latest known CD4 cell count and HIV viral load, with approximate dates for when each was obtained | |
| Currently taking medications for OUD (e.g., buprenorphine, methadone) | ____ yes ____ no |
| Treatment | |
| ARV drugs, including dosing information (e.g., dose, number of pills, dosing frequency) Images of FDA-approved ARV medications can be found at https://www.niaid.nih.gov/sites/default/files/hivpillbrochure.pdf. | |
Is the person with HIV on any LA injectable ARV drug (such as IM cabotegravir and rilpivirine, IV ibalizumab, or SQ lenacapavir)? If yes:
| ____ yes ____ no |
| Medications for treatment of OIs | |
| Medications for prevention of OIs | |
| Any investigational medications (Note: If the person is participating in a clinical trial, obtain information about the clinical trial site and contact information, if available) | |
| Other medications (include doses and dosing frequencies) | |
| 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 OIs, such as trimethoprim-sulfamethoxazole. People 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 ARV medications and other medications | |
| Key: ADAP = AIDS Drug Assistance Program; ARV = antiretroviral; CD4 = CD4 T lymphocyte; FDA = U.S. Food and Drug Administration; HBV = hepatitis B virus; HCV = hepatitis C virus; IM = intramuscular; IV = intravenous; LA = long-acting; OI = opportunistic infection; OUD = opioid use disorder; SQ = subcutaneous; VA = U.S. Department of Veterans Affairs | |
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