Wyoming Department Of Health - Communicable Disease Hiv, Hepatitis And Std Risk Assessment Page 3
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4Wyoming Department of Health – Communicable Disease HIV, Hepatitis and STD Risk Assessment
For Staff Use Only
Visit Notes:
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Areas to address with client
Check or comments
Confidentiality of records (HIPAA)
Informed Consent (as needed)
HIV/Hepatitis/STD disease transmission and education
Identify personal risk behaviors and circumstances
Offer condoms/dental dams/lube
Expedited Partner Therapy (if applicable in clinic)
Allergies
Vaccinations
Action Required
Comments
Develop Risk Reduction Plan if needed (specify plan)
Referrals made (if applicable): If more than one
Clinic Name:__________________________________________________
referral has been made, please provide that
Provider Name: ________________________________________________
information on a separate page
Phone Number:________________________________________________
Reason:______________________________________________________
Counseling and Testing
Testing and Results
Date
Test
Result (Circle One)
HIV rapid
Reactive / Non-reactive
HIV confirmatory (if applicable)
Positive/Negative
Chlamydia
Positive / Negative
Gonorrhea
Positive/ Negative
Syphilis (RPR)
Reactive (titer:____________) / Non-reactive
Syphilis Confirmatory (FTA, TPPA, etc.)
Positive/Negative
Hepatitis B Surface Antigen (HBsAg)
Positive / Negative
Hepatitis B Core Antibody – Total (HBcAb-Tot)
Reactive / Non-reactive
Hepatitis C antibody
Reactive / Non-reactive
Hepatitis C RNA
Detected / Not Detected
Staff Signature: ______________________________________________________________________ Date:__________________
Client Initials: _________________
June 23, 2016
Page 3
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