Pediatric Hiv/aids Confidential Case Report Form
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4Michigan Pediatric HIV/AIDS Confidential Case Report Form
MDHHS DATE
ENTERED:
(Patients < 13 years of age)
I. STATE HEALTH DEPT USE ONLY
Date Rec’d at
Document ID
Soundex Code
Report Status
State Number
MDHHS
MI00-
New
Update
_____/_____/______
Document Source
New Investigation
Report Medium
Surveillance Method
A_____-______-_____-______
Y
N
U
1
2
3
4
5
6
A
F
P
R
U
II. PATIENT IDENTIFIER INFORMATION – data not transmitted to CDC
Patient Legal Name:
Last:____________________ First:_______________________ Middle:________________________
last
first
middle
Birth Name (Doe, Baby Boy): Last:____________________ First:_______________________ Middle:________________________
Patient Alias Name:
Last:____________________ First:_______________________ Middle:________________________
Address Type:
Residential
Foster Home
Shelter
Current Address:________________________________ City:______________________ County:_________________________
State:______________ Zip:____________ Phone:__________________ Mobile:_________________ SS#:___________________
III. CURRENT PROVIDER INFORMATION
1
Physician:___________________________________________ Facility Name:__________________________________________
last
first
middle
City:____________________________________ State:________________ Phone: (
)________-__________________________
st
Med Rec No:_____________________________ Date 1
seen: ______/______/______ Date last seen:_____/______/_______
IV. FACILITY PROVIDING INFORMATION (
Same as Current Provider of Care)
Date form completed:____/____/_____ Person completing form:___________________________ Phone: (
)_____-___________
last
first
Facility completing form:_________________________________
Phone: (
)_____-___________
V. DEMOGRAPHIC INFORMATION – please complete ALL fields
Country of Birth:
Status:
Death
Diagnostic Status:
Sex:
Date of Birth:
Alive
Date: ___/_____/_____
US
US Depend/Posses
Perinatal HIV
____/____/_____
Male
Dead
Unk
Other___________
State/Terr of Death:
Exposure
Female
Time:_________
Unk
____________________
________________________
Pediatric HIV
Race (check all that apply):
Ethnicity:
Pediatric AIDS
Black/AA
White
Asian
Native American or Alaskan
Hispanic
Yes
No
Unk
Pediatric
Hawaiian/PI
Unknown
Other____________________
Arab
Yes
No
Unk
Seroreverter
Date of Last Medical Exam: ______/______/__________
Date of Initial Evaluation for HIV: ______/______/_________
Residence at Perinatal Exposure:
Same as Current
Street Address:_____________________________________________
City:________________________ County: _________________________ State/Country: ___________ Zip: ________________
Residence at HIV Diagnosis:
Same as Current
Street Address:__________________________________________________
City:________________________ County: _________________________ State/Country: ___________ Zip: ________________
Residence at AIDS Diagnosis:
Same as Current
Street Address:________________________________________________
City:________________________ County: _________________________ State/Country: ___________ Zip: ________________
Residence at Pediatric Seroconversion:
Same as Current
Street Address:_________________________________________
City:________________________ County: _________________________ State/Country: ___________ Zip: ________________
VI. FACILITY OF DIAGNOSIS
Facility of Perinatal Exposure:
Same as Current ____________________________ Physician: _____________________________
last
first
Address: ________________________________City: _______________________ State/Country: ____________ Zip: ______________
MRN:
Facility Type:
Private Physician
Hospital Inpatient
Hospital Outpatient
Clinic
Facility of HIV Diagnosis:
Same as Current _____________________________ Physician: _______________________________
last
first
Address: ________________________________City: _______________________ State/Country: ____________ Zip: ______________
MRN: ______________________ Facility Type:
Private Physician
Hospital Inpatient
Hospital Outpatient
Clinic
Facility of AIDS Diagnosis:
Same as Current ______________________________ Physician: _____________________________
last
first
Address: ________________________________City: _______________________ State/Country: ____________ Zip: ______________
MRN: ______________________ Facility Type:
Private Physician
Hospital Inpatient
Hospital Outpatient
Clinic
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