Colorado Health Network Medical Clinic Intake for HIV Care Patient Navigator: Admission Date: Intake Date: Client #: Referral Source: Regional Office: CONTACT INFORMATION: Client Legal Name: Proof of Legal Name: (Please Circle One) First MI Last Driver s Lic # Client Name: CO ID ID # First MI Last Medicare Card Social Security Card Pronoun(s): (Ex. he/him, she/her, they/them) Soc. Sec. Paperwork Medical Document Birth Date: Soc. Sec. Number: Birth Certificate Passport Address: Proof of residence: (Please circle one) Street Apt# Driver s Lic. # City State Zip CO ID ID # County Homeless Mail at CHN Office Medicare Card Lease Medical Document Bill May we mail CHN information to you at this address? Social Security Paperwork Phone and Email: Phone # Type: Discreet? NO CALL Message Phone # Email EMERGENCY CONTACT INFORMATION: Name Relationship Phone Discreet? Name Relationship Phone Discreet? Name Relationship Phone Discreet?
Client Demographics: Gender Male Female Trans*(MTF) Trans*(FTM) Gender Queer Gender Non-Conf. Sex Assigned at Birth Male Female Intersex Living Situation: Ethnicity Non-Hispanic Hispanic (Specify): Mexican Cuban Race (Circle all that apply) Puerto Rican Other Hispanic White Black American Indian/Alaska Native Asian (Specify): Asian Indian Chinese Filipino Japanese Korean Vietnamese Fill in Native Hawaiian/Pacific Islander (Specify): Native Hawaiian Guamanian Samoan Fill in Household, Dependents, and Roommate: Sexual Orientación Heterosexual Gay Lesbian Bisexual Pansexual Asexual Undisclosed Religious Affiliation: Language(s): (Speak Read Write) (Speak Read write) Client Country of Origin: Name Relationship Gender Ethnicity Date of Birth Custody? Name Relationship Gender Ethnicity Date of Birth Custody? Name Relationship Gender Ethnicity Date of birth Custody? Relationship Status: (Please Circle One) Single Married Committed Relationship Polyamorous/ Open Relationship Separated Divorced Client is a Child Other: Education/Employment: Education: Highest Grade Completed: Pre-HS High School Collage Graduate Post-Graduate Diploma/GED Y N Living Situation: (Circle one) Subsidized? Apartment Section 8 House/Condo HOPWA Unit Shelter TBRA Friend s Home Other With Family Homeless Group Facility Couch Surfing Employment: Employer: Full Time Part Time Volunteer: Childcare Assistance? (Please Describe Needs) Hours per Week: Hours per Week: Unemployed: Y N Time unemployed:
Income: Please List ALL Sources of Income: No Income: $ Employment $ Unemployment $ SSI How Long: $ Food Stamps $ Unreported $ SSDI $ Inheritance/Trust $ Interest Income $ VA $ Alimony $ Rental Income $ TANF $ Child Support $ Total Other Household Income: Partner/Spouse $ Parent $ Dependent $ Percent: Transportation: Cap: Does Client Qualify for Transportation Assistance? Reason for Ineligibility: Health: Medical Care / Care Team: Insurance (Select ALL that Apply) Medicaid ADAP PHIP Medicare A CICP Gilead AA Medicare B VA Gilead Co-pay QMB Other None Private, Insurance (Carrier: ) HIV Status: (Chose One) HIV Symptomatic HIV Asymptomatic AIDS Symptomatic AIDS Asymptomatic HIV/AIDS Risk Factor (Please check all that apply) Men who have had sex with men IV drug use Heterosexual contact Hemophilia/Coagulation Disorder Transactional Sex Transfusion of blood (1975-1985) blood components, or tissue Perinatal Transmission Other (Please explain): Primary on Insurance: Date of Initial Diagnosis Symptoms/Opportunistic Infection: Medicaid/Medicare/Private insurance #: Dental Insurance: Current Labs: (Please List Most Recent) CD4 Count: Date: Viral Load: Date:
HIV Health Continued: Client Treatment Status: Naïve Experienced Never on Meds (Note: Naïve Currently on HAART regimen, but no prior ART or less than one (1) month prior ART experience. Experienced: Currently on HAART regimen, and hand been on previous regimen for greater than (1) month.) Side Effect: Current Medication: (Please List ALL Current Medication, Type, and Start Date) Adherence Difficulties: Doses Missed Past Seven (7) Days: Reason Not On Meds: How do you think you were acquired with HIV? (Please select all that apply) Opposite Sex Contact Same Sex Contact Transfusion Sharing Needles Unsure Refused Pre-Natal Other (Please Describe: ) Do you have a strong support system (family/friends/partner)? Do they know your HIV Status? Are you comfortable disclosing your status to sex or drug partners? Do you have any history of sexually transmitted infections (STI s)? Have you ever tested positive for? Hepatitis B Genital Warts Non-Gonoccal (NGU) Hepatitis C Scabies Proctatitis/ Proctocolitis Gonorrhea Crabs Epidiymtis Chlamydia Pelvic Inflammatory Disease Trichomonasis Genital Herpes Cervicitis Chancroid Anal Warts Lymphogranuloma Vernerum
Health Continued: Other Medical: Have you seen a dentist in the last six (6) months? Date/Location Would you like a dental referral? Have you had an eye exam in the last year? Would you like a vision referral? Do you have any physical or mental impairment that limits normal activities, including seeing, hearing, walking, or speaking? Mental Health: Mental Health Care/Care Team: Diagnosis: Would you be interested in a counselling referral? (For what presenting issues? Please list.) Trauma History: Has anyone you know ever hit, kicked, or slapped you? Current Past Childhood Other (Please describe to the degree that you are comfortable)
Substance Use: Have you smoked Cigarettes or used other Tabaco products in the past 3 years? (Includes Vaping) On average, how many days a week do you drink alcohol? What is the maximum number of drinks that you ve had on any given day in the past month? Do you use prescription drugs outside of physician guidelines? Have you quit using any substances in the last year? Please List: In the past thirty days, have you used any of the following substances? (Outside of prescribed use) Marijuana Amphetamine (Adderall) Burprenorphine (Suboxone) Cocaine or Crack Methylphendiate (Ritalin) Methadone Methamphetamine Alprazolam (Xanax) Carisoprodol (SOMA) Inhalants/ Nitrites (poppers) Clonazepam (Klonopin) Other: Heroin Tramadol LSD Diazepam (Valium) MDMA (ecstasy/ Molly) Zolpidem (Ambien) DMT Lorazepam (Ativan) Ketamine (special K) Hydrocodone (Vicodin) Viagra, Levitra, Cialis or other sex enhance drug Morphine Hormones Oxymorphone Are you currently, or have you ever been, in treatment for substance abuse? When? SBIRT Code: Criminal History: Have you ever been involved with the criminal justice system? Have you ever been convicted of a felony? Have you been incarcerated in the last three (3) months? Questions and or Concerns: Do you have any questions or concerns you would like your medical provider to be aware of prior to your first appointment?