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SEC. \\#: Client \\#:  \nPERSONAL INFORMATION  \n\n| LAST NAME |\n| --- |\n| STREET ADDRESS |\n\nALTERNATE ADDRESS  \n\n| FIRST NAME |\n| --- |\n| CITY/STATE |\n\nCITY/STATE  \nMIDDLE INITIAL/ MAIDEN NAME  \nZIP  \nZIP  \nO. K. to Mail to Mailing address  YES  NO Anonymous return address requested  YES  NO  \nCOUNTY  \n /     \nAGE/ DOB GENDER  \n( ) May we leave message?  YES  NO Message/Day Phone ( )  HOME PHONE  \nDiscreet message only:  YES  NO May we contact you at work?  YES  NO  \nPHONE ( )   \nETHNICITY:  HISPANIC/LATINO NON HISPANIC/NON LATINO  \nRACE:  WHITE  BLACK OR AFRICAN-AMERICAN  ASIAN  OTHER  \n NATIVE HAWAIIAN/PACIFIC ISLANDER  AMERICAN INDIAN OR ALASKAN NATIVE  \nPRIMARY LANGUAGE   NEED INTERPRETER  YES  NO  \nKEY CONTACTS  \nEMERGENCY CONTACT RELATIONSHIP PHONE NUMBER  \n     ( )  AWARE OF STATUS?  YES  NO  \nHIV/AIDS PROVIDER ( )  PRIMARY CARE PROVIDER   ( )  DENTAL   ( )   \nMENTAL HEALTH   ( )   \nOTHER AGENCIES WORKING WITH CLIENT   ( )   \nPlace Client Label Here  \nCase Managers Initials:   \nDate:   \n1 of 6 Case Management Intake Updated 4/10/18  \nHEALTH INSURANCE (Check all that apply)  \n Medicaid/OHP \\#    Private Ins.    \n Date of Medicaid Eligibility    ID \\#    Medicare A & B \\#    Medicare D Provider    Veterans Benefits\\#    Dental Insurance    ADAP    Not Insured   ARE YOU EMPLOYED:  YES  NO AWARE OF HIV/AIDS STATUS?  YES  NO  \nEMPLOYER  \nADDRESS CITY/STATE/ZIP CODE  \nEDUCATION  \nHighest grade you completed in school?    \nDo you have difficulty reading?  YES  NO  \nDo you have difficulty writing?  YES  NO  \nHIV STATUS  \n HIV positive not AIDS  HIV positive, AIDS status unknown  CDC-defined AIDS  \nDate tested positive  Date of AIDS Dx:   \nTransmission Category (Check One)  \n MSM  MSM/IDU  Heterosexual  Unknown  Occupational Exposure  \n IDU  Maternal/Child  Undisclosed  Blood Products  Other  \nNON-HIV RELATED CONDITIONS  \nMEDICATIONS- Including all current medication, prescriptions, over-the-counter & experimental  \nMEDICATION PURPOSE DOSE FREQUENCY BEGAN/ REFILLED  \nDo you need help obtaining medications?  YES  NO  \nPlace Client Label Here  \nCase Managers Initials:  Date:   \n2 of 6 Case Management Intake Updated 4/10/18  \nADHERENCE NEW TO CARE  YES  NO PREVIOUSLY IN CARE  YES  NO  \nOn the average, how many appointments have you missed within the past 6 months?  \n None  1-3  3-5  5-7  7 or more  \nWhat keeps you from attending your appointments and how can we help you to keep your appointments?   Are you presently taking or have you ever taken medications for HIV (antiretrovirals)?  YES  NO What do you do when you have side effects?  \nOn average how many days per week would you say that you missed at least one dose of your HIV  \nmedications?  Every day  4-6 days/week  2-3 days/week  Once a week  \n Less than once a week  Never  \nWhat keeps you from taking your medications?   What is the hardest thing about taking your medications?   Would you like more information about medications for HIV?  YES  NO    \nLIVING SITUATION  \n Apartment  Own House  Rental House  HUD/Section 8  Adult Foster Care  \n With Friends  \n Emergency/Shelter  Personal Care Home  \n With Family  Homeless  Other  \n Transitional Housing  Skilled Nursing Facility  \n Hospice  \nDescribe current situation (Stability, safety, affordability)    \nHOUSEHOLD MEMBERS  \nMARITAL STATUS:  MARRIED  SINGLE  DIVORCE WIDOWER  PARTNER  \nNAME RELATIONSHIP TO CLIENT PHONE \\# AWARE OF HIV STATUS  \n       YES NO  \n       YES NO  \n       YES NO FAMILY MEMBER (S) WHO ASSIST WITH YOUR CARE        YES NO  \n       YES NO HOUSEHOLD MEMBERS LIVING WITH HIV  YES  NO WHO?   FAMILY DEPENDENT CHILDREN  \nDo you have dependent children?  YES  NO Names/Ages    \nIf yes, do they live with you?  YES  NO    \nDo you have any issues related to child custody?  YES  NO  \nIf yes please explain:    \nPlace Client Label Here  \nCase Managers Initials:  Date:   \n3 of 6 Case Management Intake Updated 4/10/18  \nTRANSPORTATION  \nIs transportation availabl","cbCaioicfSlvoSTh","https://ap.wps.com/l/cbCaioicfSlvoSTh","pdf",443189,6,"English","# Personal Information\n# Health Insurance\n# HIV Status and Medications\n# Adherence and Living Situation\n# Household Members\n# Transportation and Resources\n# Legal Issues\n# Prevention Screening Tool","[{\"question\":\"What client categories does the intake form support?\",\"answer\":\"It supports New Client, Updated Client, and Reactivated Client.\"},{\"question\":\"Which personal information and contact permissions does the form collect?\",\"answer\":\"It collects names, addresses, phone numbers, message permission, and whether it is OK to mail to the mailing address or use an anonymous return address.\"},{\"question\":\"What topics are covered in the prevention screening tool?\",\"answer\":\"It asks about current relationships and sexual activity, protection practices, history of STDs or Hepatitis, last TB skin test results, drug or alcohol use, treatment program attendance, and other related factors/issues.\"}]","Client Intake Form | PDF",1789792279]