Patient Baseline Assessment Flowsheet |
|
|
|
Date _____/_____/_____ |
|
NAME |
M
F |
DOB _____/_____/_____ |
Date of initial positive test |
_____/_____/_____ |
Subsequent _____/_____/_____ |
Most recent negative test |
_____/_____/_____ |
None _____ |
Sero-conversion illness |
N Y |
Approx. date _____/_____/_____ |
|
Risk factors |
|
|
|
|
Sexual contacts |
M |
F |
Both #_____ |
|
Transfusions |
Year
_____ |
|
|
|
Blood
products |
Y |
N |
|
|
Shared
hypodermics |
Y |
N |
|
|
Tattoos/piercing |
Y |
N |
|
|
Occupational |
Y |
N |
|
PMH |
|
|
|
|
|
|
|
Medications
|
|
|
|
|
|
|
|
Medication allergies or intolerances
|
|
|
|
|
|
|
|
|
|
|
|
HIV-RELATED TREATMENT
HISTORY |
||||||
|
Recent CD4+ count Date _____/_____/_____ |
Lowest CD4+ count Date _____/_____/_____ |
Recent
viral load Date _____/_____/_____ |
||||
|
MEDICATION |
DOSE |
DATE STARTED |
DATE FINISHED |
REASON
FOR STOPPING |
SIDE EFFECTS |
COMMENTS |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
AIDS defining illnesses
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Smoking |
N
Y
|
since _____/_____/_____
|
when quit _____/_____/_____ |
|
Alcohol |
drinks/day |
quit _____/_____/_____
|
|
|
|
/drinks/week |
|
|
Drugs
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
REVIEW OF
SYSTEMS
|
||
|
|
COMMENTS |
|
GENERAL |
|
|
|
Weight loss |
N Y |
|
|
Fever |
N Y |
|
|
Night seats |
N Y |
|
|
Energy decrease |
N Y |
|
HEENT |
|
|
|
Vision changes |
N Y |
|
|
Floaters |
N Y |
|
|
Sinusitis |
N Y |
|
|
Ulcers |
N Y |
|
|
Gingivitis |
N Y |
|
|
Thrush |
N Y |
|
|
|
N Y |
|
|
|
N Y |
|
|
RESPIRATORY |
|
|
|
Short of breath |
N Y |
|
|
Cough |
N Y |
|
|
|
N Y |
|
|
|
N Y |
|
CVS |
|
|
|
Chest pain |
N Y |
|
|
|
N Y |
|
|
|
N Y |
|
GI |
|
|
|
Dysphagia |
N Y |
|
|
Diarrhea |
N Y |
|
|
Abdominal pain |
N Y |
|
|
Nausea |
N Y |
|
|
Vomiting |
N Y |
|
|
|
N Y |
|
|
|
N Y |
|
REVIEW OF
SYSTEMS (continued
|
||
|
|
COMMENTS |
|
GU |
|
|
|
Discharge |
||