Form Hiv-563 - Artas Intake Screening Form Page 3
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5(INTAKE/SCREENING FORM)
HIV STATUS (
Please check appropriate boxes)
HIV-positive, not AIDS
HIV-positive, AIDS status unknown
HIV-positive, AIDS
How was status assessed:
Status self-reported
HIV Epidemiology/Surveillance
Previous Medical Records
DIAGNOSIS DATES
HIV: _____ / _____ / _______ (mm/dd/yyyy)
Estimated
AIDS (if applicable): _____ / _____ / _______ (mm/dd/yyyy)
Estimated
HIV RISK FACTORS (CURRENT)
Check all that apply
Men Who Have Sex with Men
Injection Drug User
Hemophilia/Coagulation Disorder
Heterosexual Contact
Perinatal Transmission
Unknown/Unreported
Other _
Transfusion of Blood or Blood Components
CLIENT NEEDS
I am going to read a list of services and resources. Please indicate to me which ones you currently need.
(Please indicate which of these services is most urgent for the client now)
Currently
Most Urgent
Need
(Check only one)
Drug and Alcohol abuse treatment
Housing or Shelter
Food or other subsistence needs
Dental Services
HIV-related Medical Services
Non-HIV related Medical Services
Pharmacy or Medication Services (For HIV or non HIV reasons)
Mental Health Services (inpatient or outpatient)
Other: _________________________________________________________
_______________________________________________________________
Employee’s Name: _______________________ (First)_______________________ (Last)
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Form HIV-563: ARTAS Intake Screening Form-Page
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