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Guidance for Non-HIV-Specialized Providers Caring for Persons with HIV Displaced by Disasters

Appendix A: Short Intake Form for Persons with HIV Seeking Care

Last Updated: August 31, 2017; Last Reviewed: August 31, 2017

Appendix A: Short Intake Form for Persons with HIV Seeking Care
CONTACT INFORMATION
Patient Name
Location
Phone number
E-mail address
PROVIDERS
Name, location, phone number, pager number, and e-mail address of the primary HIV care provider/clinic and research staff (if the patient is participating in a research study, such as a clinical trial)
Name, location, and phone number of the pharmacy where the patient obtained medications
MEDICAL HISTORY
Pertinent past medical history (including history of opportunistic infections [OIs] or malignancies and other medical conditions such as hypertension and diabetes mellitus)
History of hepatitis B or hepatitis C coinfection (per patient) Hepatitis B: ____ yes ____ no
Hepatitis C: ____ yes ____ no
Latest known CD4 cell count/percentage and HIV viral load, with approximate dates for when each was obtained
TREATMENT
Antiretroviral drugs, including dosing information (e.g., dose, number of pills, dosing frequency)

Images of Food and Drug Administration (FDA)-approved antiretroviral medications can be found at https://aidsinfo.nih.gov/contentfiles/ upload/HIV_Pill_Brochure.pdf.
Any investigational medication

(if the patient is participating in a clinical trial, obtain information about the clinical trial site and contact information, if available)
Medications for treatment of OIs


Medications for prevention of OIs


Other medications


DRUG ALLERGIES/INTOLERANCE
History of drug allergy and type of reactions. Especially note allergies to abacavir, or drugs used for treatment or prevention of OIs, such as trimethoprim-sulfamethoxazole. Patients who have had positive genetic tests for the HLA-B* 5701 allele should not be given abacavir (Ziagen™) or fixed-dose combinations containing abacavir (Epzicom™, Trizivir™, or Triumeq™).
History of intolerance to antiretroviral medications and other medications

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