Michigan Adult Hiv Confidential Case Report Form Page 2
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2X. DOCUMENTED LAB DATA
PATIENT NAME:___________________________________
*Questions concerning lab results? CALL US at 248 424-7922 or 517 335-8165*
*You may add copies of lab results to this form and may
*
HIV DIAGNOSTIC TESTS – please report all positive and subsequent negative tests
Type of Test
Collection
***At least 2 Antibody Tests must be indicated for
an HIV diagnosis***
Date
IA = ImmunoAssay
th
Gen Discriminating)
HIV-1/2 Ag/Ab Lab IA (4
N
Alere
th
Gen Discriminating)
HIV-1/2 Ag/Ab Rapid IA (4
Y
Determine
th
HIV-1/2 Ag/Ab Lab IA (4
Gen)
N
nd
rd
HIV-1/2 Ab IA (2
or 3
Gen)
Y N
Multispot or
HIV1/HIV 2 Type Differentiating IA
Y
Geenius
HIV-1 Western Blot
N
HIV-1 RNA/DNA Qualitative NAAT
N
OTHER:____________________________
Last Negative Test (prior to HIV diagnosis)
Y 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 at or closest to current diagnostic status
CD4 Count______________cells/ul
CD4 Percentage_____________% Collection Date_______/__________/__________
First CD4 Count <200 total lymphocytes
CD4 Count______________cells/ul
CD4 Percentage_____________% Collection Date_______/__________/__________
HIV Genotype
Sanger Sequence
Deep or NextGen Sequence
Collection Date________/__________/_________
XI. STAGE 3 (AIDS) OPPORTUNISTIC ILLNESSES (See Instructions for a list of opportunisitic illnesses)
Name of Opportunistic Illness:_______________________________ Illness Diagnosis Date_______/________/__________
XII. HIV TESTING AND TREATMENT HISTORY (TTH)
Date questions answered by patient: _______/_______/________
Main Source of TTH Info:
Medical Record Review
Patient Interview
Provider Report
Other
First Positive Test Reported by Patient:
Negative Tests Reported by Patient:
Ever have previous positive HIV test?
Y
N
Unk
Ever test negative?
Y
N
Unk
st
Date of 1
positive HIV test:______/______/_______
Date of most recent negative test: ______/______/_______
st
Anonymous 1st positive test?
Y
N
Unk
# of negative tests in 24 mo. before 1
positive test:______
Unk
History of ANY Antiretroviral Treatment (ARV) Use: CHECK HERE IF NO ARV USE EVER:
For HIV Tx?
ARV used:___________________Date began: _____/_____/______ Date of last use: _____/_____/______
For PrEP?
ARV used:___________________Date began: _____/_____/______ Date of last use: _____/_____/______
For PEP?
ARV used:___________________Date began: _____/_____/______ Date of last use: _____/_____/______
For Preg mom? ARV used:___________________Date began: _____/_____/______ Date of last use: _____/_____/______
For Hep B Tx?
ARV used:___________________Date began: _____/_____/______ Date of last use: _____/_____/______
Currently using ARV?
Yes, Date of most recent use: _____/_____/______
No, Date of last use: _____/______/______
XIII. COMMENTS
_______________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
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