Pediatric Hiv/aids Confidential Case Report Form Page 2
ADVERTISEMENT
1
2
3
4Patient Name:_____________________________ State No:____________________
last
first
VII. PATIENT/MATERNAL HISTORY – please complete ALL fields
Mother’s Country of Birth:
Mother’s Demographics:
HEALTH DEPT USE ONLY
Mother’s Soundex
US State: _____________
Mother’s Name: _______________________________
last
first
middle
US Depend/Posses
Mother’s SS#: ________________________________
Mother’s State Number
Unknown
Other: __________
Mother’s Date of Birth: ____/____/_____ G____ P____
Child’s biological mother’s HIV infection status (check one):
Refused HIV testing
Known UNINFECTED after birth
Unknown
Known HIV positive before pregnancy
Known HIV positive at time of delivery
Known HIV positive sometime after birth
Known HIV positive during pregnancy
Known HIV positive sometime before birth
HIV positive with time unknown
Mother was counseled about HIV testing during this pregnancy,
Date of mother’s first positive HIV confirmatory test ____/____/_____
labor or delivery?
Yes
No
Unknown
Before their first positive HIV test/AIDS diagnosis this
Before their first positive HIV test/AIDS
Y
N
U
Y
N
U
child’s mother had:
diagnosis this child had:
Perinatally acquired HIV infection
Injected non-prescription drugs
Received clotting factor for hemophilia/coagulation
Injected non-prescription drugs
disorder
Received transfusion of blood/blood components (other than
Received transfusion of blood/blood components (other
clotting factor)
than clotting factor)
Received transplant of tissue/organs or artificial insemination
Received transplant of tissue/organs
HETEROSEXUAL SEX WITH:
Sexual contact with a male
- An injection drug user (IDU)
Sexual contact with a female
- A bisexual male
Other documented risk
- A male with hemophilia/coagulation disorder
No identified risk factor (NIR)
- A transfusion recipient with documented HIV infection
- A transplant recipient with documented HIV infection
- A male with AIDS or documented HIV infection, risk not
specified
VIII. HIV DIAGNOSTIC TESTS – please report all positive and subsequent negative tests
*You may add copies of lab results to this form and may fax form to 248 424-9161(SE MI)
Type of Test
**At least 2 Antibody Tests must be indicated for an HIV
Collection
Date
diagnosis**
IA = ImmunoAssay
HIV-1/2 Ag/Ab Lab IA
N
(Discriminating & Differentiating Screen)
th
HIV-1/2 Ag/Ab Lab IA (4
Gen)
N
Multispot or
HIV1/HIV 2 Type Differentiating IA
Y
Geenius
HIV-1 RNA/DNA Qualitative NAAT
N
HIV-1 RNA/DNA Qualitative NAAT
N
HIV-1 RNA/DNA Qualitative NAAT
N
If HIV lab tests were NOT documented, is HIV diagnosis confirmed by a clinical care provider?
Yes
No
Unk
IF YES, please provide date of documentation by care provider:________/________/__________
HIV CARE TESTS
HIV-1 RNA Assay Quantitative Viral Load
Detectable
Undetectable
Copies/mL ________________
Collection Date________/__________/_________
Detectable
Undetectable
Copies/mL ________________
Collection Date________/__________/_________
CD4 Count
CD4 Count______________cells/ul
CD4 Percentage_____________% Collection Date_______/__________/__________
CD4 Count______________cells/ul
CD4 Percentage_____________% Collection Date_______/__________/__________
HIV Genotype
Sanger Sequence
Deep or NextGen Sequence
Collection Date________/__________/_________
Page 2 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business