Patient Baseline Assessment Flowsheet |
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Date _____/_____/_____ |
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NAME |
M
F |
DOB _____/_____/_____ |
Date of initial positive test |
_____/_____/_____ |
Subsequent _____/_____/_____ |
Most recent negative test |
_____/_____/_____ |
None _____ |
Sero-conversion illness |
N Y |
Approx. date _____/_____/_____ |
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Risk factors |
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Sexual contacts |
M |
F |
Both #_____ |
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Transfusions |
Year
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Blood
products |
Y |
N |
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Shared
hypodermics |
Y |
N |
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Tattoos/piercing |
Y |
N |
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Occupational |
Y |
N |
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PMH |
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Medications
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Medication allergies or intolerances
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HIV-RELATED TREATMENT
HISTORY |
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Recent CD4+ count Date _____/_____/_____ |
Lowest CD4+ count Date _____/_____/_____ |
Recent
viral load Date _____/_____/_____ |
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MEDICATION |
DOSE |
DATE STARTED |
DATE FINISHED |
REASON
FOR STOPPING |
SIDE EFFECTS |
COMMENTS |
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AIDS defining illnesses
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Smoking |
N
Y
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since _____/_____/_____
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when quit _____/_____/_____ |
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Alcohol |
drinks/day |
quit _____/_____/_____
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/drinks/week |
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Drugs
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REVIEW OF
SYSTEMS
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COMMENTS |
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GENERAL |
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Weight loss |
N Y |
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Fever |
N Y |
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Night seats |
N Y |
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Energy decrease |
N Y |
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HEENT |
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Vision changes |
N Y |
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Floaters |
N Y |
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Sinusitis |
N Y |
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Ulcers |
N Y |
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Gingivitis |
N Y |
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Thrush |
N Y |
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N Y |
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N Y |
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RESPIRATORY |
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Short of breath |
N Y |
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Cough |
N Y |
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N Y |
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N Y |
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CVS |
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Chest pain |
N Y |
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N Y |
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N Y |
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GI |
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Dysphagia |
N Y |
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Diarrhea |
N Y |
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Abdominal pain |
N Y |
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Nausea |
N Y |
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Vomiting |
N Y |
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N Y |
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N Y |
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REVIEW OF
SYSTEMS (continued
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COMMENTS |
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GU |
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Discharge |
N Y |
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Urinary symptoms |
N Y |
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Sexual function |
N Y |
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N Y |
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N Y |
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N Y |
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N Y |
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Pelvic |
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Menstrual abnormality |
N Y |
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Dyspareunia |
N Y |
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Vaginal discharge |
N Y |
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Contraception |
N Y |
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N Y |
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N Y |
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Dermatologic |
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Rash |
N Y |
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Shingles |
N Y |
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Dryness |
N Y |
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N Y |
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CNS |
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Headaches |
N Y |
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Paresthesias |
N Y |
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Memory loss |
N Y |
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Mood abnormalities |
N Y |
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Nutrition:
Exercise:
EXAMINATION |
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Ht |
Wt |
BP / |
P /min |
RR /min |
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Temp |
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NORMAL |
ABNORMAL
FINDINGS |
H and N |
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Chest |
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Adenopathy |
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Breast |
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CVS |
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Abdominal |
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Rectal |
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Genital |
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Pelvic |
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MSK |
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Skin |
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CNS |
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Assessment:
Plan:
SCREENING TESTS |
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TEST |
DATE |
RESULT |
ACTION TAKEN |
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Syphilis |
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Confirmatory |
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Anti-HAV |
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HepBsAg |
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Anti-HepBs |
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Anti-HCV |
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Toxoplasma |
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Cytomegolovirus IgG |
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Two-step Mantoux #1 |
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#2 |
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Chest x-ray (if necessary) |
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VACCINATIONS |
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RECOMMENDED |
DATE |
DATE OF BOOSTERS |
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Tetanus-diphtheria |
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q10yrs |
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Inactivated polio |
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Pneumococcal |
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q5yrs |
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Influenza |
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yearly |
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Hepatitis B
1 @ month 0 |
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2 @ month 1 |
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3 @ month 6 |
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CONSIDER |
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Haemophilus Influenza type
B (HiB) |
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Hepatitis A
1 @ month 0 |
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2 @ month 6 |
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OTHER |
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NAME: |
DOB: |
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DATES
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Weight |
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CD4 |
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CD4% |
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CD4+/CD8+ |
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Viral Load |
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Log VL |
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WBC |
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Hb |
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Plt |
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Creatinine |
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AST/ALT |
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ALP |
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Bili |
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CK |
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LDH |
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Amylase |
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Chol |
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TG |
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Glucose |
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B12 |
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Follate |
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Testosterone-Free |
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Testosterone-Total |
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TSH |
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PAP |
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NAME: |
DOB: |
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DATES
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Antiretrovirals |
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OI prophylaxis |
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Other meds |
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Vaccines given |
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Comments: |
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