SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 71: MEDICAL HEALTH FORM INSTRUCTIONS

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 71: Medical Health Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

This module should be completed only by a knowledgeable health-care provider; it should not be distributed to nor filled in by the patient.

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the sides of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks for the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Specific Parts of the Module 71: Medical Health Form

1st Medical Visit / Return Visit. Darken the circle next to "1^st Medical Visit" if this is the client’s first medical visit. Darken the circle next to "Return Visit" if this visit is a continuing care visit.

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. Site codes are 3 letters.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

Date. Enter the numbers representing today’s date (the date of the activity or on which services were provided) in these boxes. Enter the month as a number from 01 to 12 corresponding to January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "96" for 1996). Make sure that if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure that each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the staff who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

Client Gender. Use your observations to determine if client is male or female. If the client is biologically male, darken the circle next to "Male." If the client is biologically female, darken the circle next to "Female." Ask him or her if necessary.

Viral Load. In the boxes provided write in the number of RNA copies. To the right of the boxes indicating viral load, darken the circle next to the method that was used to determine the viral load.

CD4 Plus Lymphocyte Count. In the boxes provided, enter the person’s most recent CD4 + lymphocyte count and CD4%. Also, darken the circle next to the appropriate CDC classification based on CD4 count.

Karnofsky Rating Scale. On this scale is recorded the client’s current performance status (or level of functioning) as indicated by the clients ability to perform common tasks. The scale ranges from 0 to 100% with a rating of 0% equal to the client being dead and a rating of 100% equal to the client being normal and manifesting no signs of disease. Darken the one bubble next to the description most suited to the client’s highest level of functioning. According to the Scale, individuals who score at 100% exhibit normal activity. Those who score at 80% are symptomatic but ambulatory and can care for themselves. Those who rate at 60% are ambulatory more than 50% of the time but occasionally need assistance. Persons who rate at 30% are ambulatory 50% or less of time and tend to need nursing care. Last, persons who rate at 10% are bedridden and may need hospitalization.

HIV-Related Symptoms. Darken the circle next to the symptom (s) that the client has experienced.

Medical Conditions. Darken the circle next to the client’s observed or reported medical conditions. Note that there is a space for "Other" in which you may write in a medical condition not listed on the form.

Since Last Visit. Indicate the number of emergency room visits, hospitalizations, primary care provider visits and visits to specialists that the client has made since the last visit. Indicate the number of times for each type of visit by darkening the circle next to the appropriate number.

Opportunistic Infections (all that apply). For each opportunistic infection darken the circle under "History" if the client has ever had the infection. Darken the circle under "Current" if the client presently has the infection.

ICD-9 Codes. In the boxes provided, enter up to as many as seven ICD-9 codes.

Laboratory. Enter laboratory results in the boxes provided.