PATHWAYS TO WELLNESS/ACP INITIAL INTAKE FORM
Welcome to Pathways To Wellness. Please complete the following form in detail. All information on this form is
confidential and will be seen only by our staff unless you give written authorization to release information.
First Name: ____________________________ MI:_____ Last Name:____________________________
Address ___________________________________________________________________________________
City: ___________________________________ State:________
Housing O Permanent O Non-permanent O Institution O Other Phone: day ______________________ eve _________________________ cell ______________________
We typically confirm treatment appointments by phone a day in advance.
What is your preferred phone number for confirmation calls? (circle one) Day / Eve / Cell Mandatory: Our public funds providers require that clients be assigned a client code. It is comprised of:
___ ___ ___ ___/___/___ ______-____-______
First 3 letters of your mother’s FIRST name Date of Birth Social security number Gender: O Male O Female O Transgender O Intersex
Emergency Contact:______________________ Contact Phone: _______________________
Primary Physician & hospital affiliation: __________________________________________
How many hours do you work or volunteer/week? _______ Occupation: _________________
Email: ______________________________________________________________________
We will never sell or transfer your information to third parties. We would like to send you our newsletter or information by email. May we? ( ) Yes ( ) No
Referral Information: Please Check One O Counseling/testing Site Please select ALL that apply (you MUST select at least one) O White
O Native Hawaiian/Pacific Islander O American Indian/Alaskan native O Unknown/unreported In addition to your choice above, you may select additional groups below: O African Ethnicity: Required in this format by our state and federal funds providers Do you have Latino ancestry
O No O Yes Specify: ___________ O Unknown
Primary Language: Is English your second language: If you would like us to know how you identify: O gay/MSM O straight O transgender O Lesbian/WSW O bisexual O questioning HAVE YOU EVER BEEN TESTED FOR:
Results: O HIV+
Results: O Positive O Negative O Chronic Carrier
Results: O Positive O Negative
Results: O Positive O Negative O Chronic Carrier
Results:
If Hepatitis C: Results of liver function tests
4/2005 Pathways to Wellness, Inc. Confidential use only.
PATHWAYS TO WELLNESS/ACP INITIAL INTAKE FORM If you have HIV/AIDS, please fill out information asked in this box: O HIV+ (not AIDS) O HIV+ (AIDS status unknown) O AIDS (CDC-defined) Date of HIV+ diagnosis: _______________ Date of AIDS diagnosis: ________________ Month/Day/Year
Last CD4 count: (T cell count) __________ CD4 Date:_____________ (Month/Day/Year)
Last Viral Load: ______________ Viral Load Date: _____________(Month/Day/Year) How do you think you were infected with HIV? [Please check all that apply – required by funds providers] O Men who have sex with men (MSM)
O Hemophilia/coagulation disorder O Bisexual O Receipt/transfer of blood, blood O
During the last month, how often did you drink alcohol? O never
During the last 12 months have you used street drugs?
In your opinion, are you currently abusing alcohol or drugs?
Are you in recovery? O Yes O No For how long? ____________ Are you currently in a drug/alcohol treatment program?
Have you ever attempted or seriously thought about suicide?
Are you currently in therapy/counseling?
CURRENT HEALTH
What are the main symptoms/problems you seek treatment for?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
In the past 12 months have you required?
Hospitalization? O Yes O No # Days________ For ______________________________
Visits to the Emergency Room? O Yes O No # Visits ______ For _____________________
Home care services? O Yes O No If yes, please describe______________________________
Please list any previous surgeries, hospitalizations, and serious illnesses with dates: _____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4/2005 Pathways to Wellness, Inc. Confidential use only.
PATHWAYS TO WELLNESS/ACP INITIAL INTAKE FORM WESTERN MEDICAL DIAGNOSIS Please check off any Western Diagnosis you have now or have had in the past:
O pneumonia: what type___________________________
O cancer: what type ______________________________
O mental health issues: what type _________________________________________________________________
O Allergies: what drugs or substances______________________________________________________________
_____________________________________________________________________________________________ DIAGNOSTIC QUESTIONS Please indicate all symptoms below that you have experienced within the past 30 days. Please circle according to the severity of your symptoms L=Light M=Medium S=Strong If you do not have the symptom, do not circle anything.
HEAD, EYES, EARS, NOSE, THROAT L M S sinus problems
L M S other (specify)__________________________
RESPIRATORY L M S shortness of breath
L M S other (specify)_________________________
GASTROINTESTINAL L M S loss of appetite
L M S other, specify: ____________________
4/2005 Pathways to Wellness, Inc. Confidential use only. PATHWAYS TO WELLNESS/ACP INITIAL INTAKE FORM CARDIOVASCULAR GENITO-URINARY
L M S other, specify________________________
MUSCULAR/SKELETAL
L M S pain, tingling or numbness in arms, legs, fingers, toes/ neuropathy
NEUROLOGICAL/PSYCHOLOGICAL
L M S other, specify _________________________
SKIN/HAIR/NAILS OTHER SYMPTOMS
L M S other________________________________________________________________
GYNECOLOGICAL/OBSTETRICS
L M S Other ________________________________________________________
Menstrual Info: ____ days bleeding ____ day cycle date last period ___________ Do you take Hormone Replacement Therapy?
Please alert your practitioner if you become pregnant. Your treatment will be modified to support a healthy pregnancy. Are you in menopause?
How many pregnancies have you had? ______
Date last pap smear ________________ NORMAL ABNORMAL Last breast exam _________________ NORMAL ABNORMAL
4/2005 Pathways to Wellness, Inc. Confidential use only.
PATHWAYS TO WELLNESS/ACP INITIAL INTAKE FORM Please list all HIV – medications you currently use:
O Check if no current western medications used
O Check if currently taking HIV medications (Please check off all current medications below)
O Check if currently on a Structured Treatment Interruption (“drug holiday”)
Adherence Level: Overall in the past month, have you taken your prescribed medications: O Almost never O Less than 50% of the time O 50% of the time O Routinely Anti-viral drugs O AZT (Retrovir) Protease Inhibitors: O Ritonavir
Anti-Retrovirals O
Anti-Depressants/Anti anxiety/Sleep O Secondary Conditions: O Reverse Transcriptase Inhibitors: O Viramune (nevirapine)
Other: O Multi vitamin O HRT
4/2005 Pathways to Wellness, Inc. Confidential use only.
PATHWAYS TO WELLNESS/ACP INITIAL INTAKE FORM WESTERN MEDICATIONS Please list any medications not included on page 5: I do not take any O Western medications Medication/Supplement/Herb Side-Effects Experienced
1._______________________________________________________________ 2._______________________________________________________________ 3._______________________________________________________________ 4._______________________________________________________________ 5._______________________________________________________________ 6._______________________________________________________________ 7._______________________________________________________________ 8._______________________________________________________________ 9._______________________________________________________________ 10.______________________________________________________________ 11.______________________________________________________________ 12._____________________________________________________________
Client Signature:___________________________________________Date:_______________ ADMINISTRATIVE USE ONLY
Referrals needed for:_________________________________________________________
Referrals made to:___________________________________________________________
Misc:_____________________________________________________________________
__________________________________________________________________________
Reviewing Acupuncturist: ____________________________Date:____________________
Weight:_______________ Kscore:_________________ TREATING PRACTITIONER SHOULD GENERATE TREATMENT PLAN
4/2005 Pathways to Wellness, Inc. Confidential use only.
Sensors 2003 , 3, 524-533 sensors ISSN 1424-8220 Voltammetric Determination of Prochlorperazine and Ethopropazine Using a Gold Electrode Modified with Decanethiol SAM Yuxia Yang, Yan Peng, Faqiong Zhao and Baizhao Zeng* Department of Chemistry, Wuhan University, Wuhan 430072, P. R.China *Author to whom correspondence should be addressed. E-mail: zengbz@chem.whu.