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