Kentucky Hiv Test Form Page 2
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5PART 2
KENTUCKY HIV TEST FORM
KY Sticker Number
Was the client referred to HIV medical care?
ARV Medications
□
No
Reason the client was not referred to HIV medical care?
22
Agenerase
□
□
Client Already in Care
Client Declined Care
□
30
Aptivus
Yes
Did the client attend the first appointment?
□
□
Pending
Confirmed: Accessed Service
First medical appointment within
32
Atripla
□
□
Lost to Follow-Up
Confirmed: Did Not Access Service
90 days of the HIV test?
□
□
□
No Follow-Up
Don’t Know
Yes
24
Combivir
□
No
□
□
Don’t Know
Don’t Know
38
Complera
Was the client referred to/contacted by Partner Services?
06
Crixivan
□
No
37
Edurant
□
Yes
Was the client interviewed for Partner Services?
□
□
Don’t Know
No
11
Emtriva
□
Yes, within 30 days of receiving their result
□
Yes, but not within 30 days of receiving their result
03
Epivir
□
Yes, but I don’t know within how many days of receiving their result
□
28
Epzicom
Don’t Know
25
Fortovase
Was the client referred to HIV Prevention Services?
□
No
10
Fuzeon
□
Yes
Did the client receive HIV Prevention Services?
□
□
19
Hepsera
Don’t Know
No
□
Yes
□
02
Hivid
Don’t Know
23
Hydroxyurea
What was the client’s housing status in the past 12 months? (check all that apply)
□
□
□
18
Invirase
Literally Homeless
Unstably Housed and at Risk of Losing Housing
Not Asked
□
□
□
Imminently Losing Housing
Stably Housed
Declined to Answer
34
Intelence
□
Don’t Know
36
Isentress
If female, is the client pregnant?
16
Kaletra
□
No
□
Yes
Is the client in prenatal care?
31
Lexiva
□
□
□
Don’t Know
No
Declined
□
□
□
Declined
Yes
Not Asked
07
Norvir
□
□
Not Asked
Don’t Know
33
Prezista
Prior to the client testing positive during this test event, was she/he previously reported to the state’s surveillance department as
being HIV-positive?
09
Rescriptor
□
□
□
□
No
Yes
Don’t Know
Not Checked
26
Retrovir
Date the client reported information
15
Reyataz
_______________________
08
Saquinavir
(MM/DD/YYYY)
35
Selzentry
Has the client ever had a previous positive HIV test?
39
Stribild
□
No
□
Yes
Date of first positive HIV test: _______________________
21
Sustiva
□
Don’t Know
(MM/DD/YYYY)
□
Declined
13
Trizivir
Has the client ever had a negative HIV test?
27
Truvada
□
No
01
Videx
□
Yes
Date of first negative HIV test: _______________________
□
Don’t Know
(MM/DD/YYYY)
14
Videx EC
□
Declined
17
Viracept
Number of negative HIV tests within 24 months before the current (or first positive) HIV test
05
Viramune
□
___________
Don’t Know
□
(# # #)
Declined
12
Viread
Has the client used or is the client currently using antiretroviral medication (ARV)?
04
Zerit
20
Ziagen
□
No
□
Yes
Specify ARV medications:
______
______
______
______
88
Other
□
Don’t Know
(use codes on the right)
(# #)
(# #)
(# #)
(# #)
99
Unspecified
□
Declined
Date ARV began: _______________________
Date of last ARV use: _______________________
(MM/DD/YYYY)
(MM/DD/YYYY)
Revised: 10/23/2017 (GCL)
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