Form Cdc 50.42a - Adult Hiv Confidential Case Report Form Page 4
ADVERTISEMENT
1
2
3
4Treatment/Services Referrals
(record all dates as mm/dd/yyyy)
Has this patient been informed of his/her HIV infection?
This patient’s partners will be notified about their HIV exposure and counseled by:
□
□
□
□
□
□
□
Yes
No
Unknown
1-Health Dept
2-Physician/Provider
3-Patient
9-Unknown
For Female Patient
This patient is receiving or has been referred for gynecological or
Is this patient currently pregnant?
Has this patient delivered live-born infants?
□
□
□
□
□
□
□
□
□
obstetrical services:
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
For Children of Patient
(record most recent birth in these boxes; record additional or multiple births in the Comments section)
*Child’s Name
Child Soundex
Child’s Date of Birth
*Child’s Coded ID
Child’s State Number
Hospital of Birth (if child was born at home, enter “home birth” for hospital name)
Hospital Name
*Phone
*ZIP Code
*Street Address
City
County
State/Country
HIV Testing and Antiretroviral Use History
(if required by Health Department) (record all dates as mm/dd/yyyy)
Main source of testing and treatment history information (select one)
Date patient reported information
□
□
□
□
□
Patient Interview
Medical Record Review
Provider Report
NHM&E/PEMS
Other
__ __ /__ __ /__ __ __ __
□
□
□
□
Date of first positive HIV test
Ever had previous positive HIV test?
Yes
No
Refused
Don’t Know/Unknown
__ __ /__ __ /__ __ __ __
Date of last negative HIV test
(If date is from
□
□
□
□
__ __ /__ __ /__ __ __ __
Ever had a negative HIV test?
Yes
No
Refused
Don’t Know/Unknown
a lab test with test type, enter in Lab Data section)
□
□
Number of negative HIV tests within 24 months before first positive test # _____________
Refused
Don’t Know/Unknown
□
□
□
□
If Yes, ARV medications:
Ever taken any antiretrovirals (ARVs)?
Yes
No
Refused
Don’t Know/Unknown
Dates ARVs taken
Date first began:
Date of last use:
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
*Comments
*Local/Optional Fields
CDC 50.42A
Rev. 3/2013
(Page 4 of 4)
—ADULT HIV CONFIDENTIAL CASE REPORT—
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal