Newcomer Health Supplemental Data Collection Form
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1Country of
Origin:______________________
Newcomer Health Program
Country of
Supplemental Data Collection Form
Exit:________________________
Place Patient ENCOUNTER Label Here:
Alien ID#:
_____________________________
Date of Arrival in US:
_____________________________
Name:______________________________________________________
VOLAG:
_____________________________
DOB:____________________________ Pt #:________________________
Health District:
_____________________________
Encounter #:_________________________________
Yes No DATE OF INITIAL ASSESSMENT:_____/______/________
Did the patient receive an initial health screening?
Moved Refused Never located Missed multiple appts.
If the patient did not receive a screening, why not?
Unknown
Other_____________________________
Please provide an appropriate response to each question.
Assessment Findings: Is the patient: Male Female
Yes No
N/A Referral needed?
Yes No
Was the dental evaluation WNL?
Yes No
N/A Referral needed?
Yes No
Was the hearing evaluation WNL?
Yes No
N/A Referral needed?
Yes No
Was the vision evaluation WNL?
Yes No
Yes No
Were nutritional abnormalities found?
Referral needed?
Yes No
Yes No N/A
For children, was the developmental assessment WNL?
Referral needed?
Not Done
Pos Neg. Referral needed?
Yes No
If female, was the pregnancy test:
Not Done
Yes No
Yes No
Was the mental health screening WNL?
Referral needed?
Was the patient referred for follow up on any of the following? (Check all that apply.)
Diabetes
HTN
Mental Health
Suicidal Thoughts
Neurology
GI Issues
Orthopedics
OBGYN
Infectious Disease
HIV
Elevated Cholesterol
Disability Services
Other (specify)______________________________
Yes No
Was the client referred/linked to a Primary Care Provider?
Laboratory Findings:
Not Done
Yes No
Yes No
Was the CBC WNL?
Referral needed?
Not Done
Yes No
Yes No
Was the metabolic panel WNL?
Referral needed?
Were the HepB Surface Antigen Results WNL? Not Done
Yes No
Yes No
Referral needed?
Not Done
Yes No
Yes No
Was the HIV result WNL?
Referral needed?
Not Done
Yes No
Yes No
Was the RPR result WNL?
Referral needed?
Not Done
Yes No
Yes No
Was the Urinalysis WNL?
Referral needed?
Not Done
Yes No
Yes No
Were the Hepatitis C results WNL?
Referral needed?
Tuberculosis Screening:
Comments:________
_________________
Pos Neg. Not Done
Test for TB infection (TST or IGRA)
Yes No
Not Done
_________________
If the patient was referred for a chest x-ray was it WNL?
_________________
Yes No
Yes No
Was treatment recommended for:
Active TB Disease?
LTBI?
Person Completing Form:___________________________________ Phone #:(____)__________________
Print Name (Last Name, First Name)
Forms MUST be returned within 30 days of assessment in order for the LHD to receive reimbursement.
Please FAX completed forms to the Newcomer Health Program at (804)864-7913
Revised 2/11/14
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