Microsoft word - acpintakeform.06.rtf

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.

Source: http://www.pathwaysboston.org/downloads/ACPIntakeform.061.pdf