Form Dhas -9 - Client Intake Record
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1DHAS-9
New Jersey Department of Health
CLIENT INTAKE RECORD
JUL 12
Division of HIV, STD and TB Services - HIV Home Care Program
Last Name
First Name
Middle Initial
1. Name of Agency
2. Case Manager
RN
MSW
3. Intake Date
____/____/____
Month / Day / Year
4. ID Number
5a. Name of Referring Hospital/Agency
5c. Referral Date
____/____/____
-
____
____ ____ ____ ____
Month / Day / Year
5b. Agency Type:
1st
+
Last 4 Digits of
Client
Clinic/Social Service Agency
6. Enrollment Date
Letter of
Social Security
Hospital
Social Worker
Last Name
Number
Physician
Friend/Family
____/____/____
____________________
Other, Specify:
Month / Day / Year
7. City
8. County
9. Zip Code
10. Is client being re-enrolled into the HIV Home Care Program?
: ________________________________________________
Yes
No
If Yes, specify reason for re-enrollment
13. Gender
11. Race
12. Hispanic or Latino/a Ethnicity
Male
American Indian or Alaskan Native
More than one race
Hispanic or Latino/a
Female
Asian
Unknown/Unreported
Non-Hispanic or Non-Latino/a
Transgender
Black or African American
White
Unknown/Unreported
Unknown/Unreported
Native Hawaiian or Other Pacific Islander
14. Date of Birth
16. Living Arrangement
Homeless/Shelter
Living Alone
Living with Spouse
____/____/____
Living with Friend
Living with Relative(s)
Living with Children-
Month / Day / Year
_____
Living in Group Facility
Living with Parents/Guardian
(No. of Children Under 18:
)
15. Age
Other
17. Current Employment Status (Check ALL that apply)
18. Number of Persons
19. Gross Monthly Household
Employed Full Time (35 or More Hours/Week)
Living in Household:
Income from ALL Sources:
Employed Part Time (Less Than 35 Hours/Week)
__________
Medically Disabled
_____________
$
Not Employed
20. Does client have health insurance coverage?
21. Has health insurance coverage been applied for?
Yes
No
Date Application Sent
Yes
No
If Yes, complete the following:
(Month/Year)
If No, complete Question 21
____/____
If Yes, complete the following:
SSI
Private Insurance
____/____
SSD
____________________________
Specify:
____/____
ACCAP
Medicare
____/____
Medicaid
Medicaid
______________
____/____
Other:
Other
______________________________
If No, explain:
____________________________
Specify:
When will application be
____/____
completed and mailed?
22. Has client tested positive for HIV?
23. Has client been diagnosed with AIDS?
Yes
No
Yes
No
____
____
____
____
If Yes, what is the date of the test?
/
If Yes, what is the date of the test?
/
Cannot recall date.
Month/Year
Cannot recall date.
Month/Year
24a. Medical Diagnoses RELATED to HIV/AIDS:
24b. Medical Diagnoses UNRELATED to HIV/AIDS:
1. ________________________________________
1. ________________________________________
2. ________________________________________
2. ________________________________________
3. ________________________________________
3. ________________________________________
25. Exposure Category (Check ALL that apply)
Men Who have Sex with Men (MSM)
Receipt of blood transfusion,
Undetermined/unknown/risk not
Injection Drug User (IDU)
blood components or tissue
reported or identified
Men Who Have Sex with Men and IDU
Heterosexual Contact
HIV Positive Mother
Other
Hemophilia/Coagulation Disorder
26a. Client Needs (Check ALL that apply)
26b. Assistance With
Intravenous Therapy
Drug Education
Transferring
Dressing
Toileting
Shopping
Laundry
Oxygen Therapy
Drug Monitoring
Walking
Bathing
Meal Preparation
Housekeeping
______________________
________________________________________________
Other:
Other:
27a. Overall Condition
27b. Cognitive
28. Circle the Estimated Number of Months HIV HCP Services
Impairment
Will Be Required
Good
Fair
Poor
Terminally Ill
Wasting
1
2
3
4
5
6
7
8
9
10
11
12
Yes
No
29a. Supervisor
29b. Date
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