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pdfPatient Navigator Outreach and Chronic Disease Prevention Program
Patient Intake Form
Study ID:
Enrollment Date:
Subsite:
Demographics
Household
Gender (Check one) *
Male
Female
Transgender
3-digit zip prefix
Birth year *
__ __ __
Household size
__ __ __ __
Ethnicity (Check one) *
Hispanic or Latino
Non-Hispanic
Race (Check all that apply)
White
Black/African American
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaska Native
Refused
Optional race coding:
Primary/preferred language *
(Check one)
English
Spanish
Chinese
Fijian
Filipino
Tagalog
French
Ilocano
Haitian Creole
Visayan
Hmong
Other
Japanese
Korean
Micronesian
Chuukese
Mixteco
Kosraean
Navajo
Marshalese
Samoan
Pohnpeian
Somali
Yapese
Tongan
Vietnamese
Other
Specify:
Rev. 19-Sep-2011
Navigated Condition(s)
Refused
Education (Check one)
No formal education
Primary education only
Some HS/secondary education
HS Diploma/GED/other secondary
education
Some college/vocational school/
other post-secondary education
Completed college, post-secondary
or vocational school
Post-college/graduate school
Refused
* Required for registration
Local Identifiers (site use only)
Navigator:
__ __
Refused
(# in household, Including patient)
Household income (Check one)
Less than $10K
$10K to $19,999
$20K to $29,999
$30K to $39,999
$40K to $49,999
$50K or more
Refused
Utilization
# Hospital stays, past year
None
One stay
More than 1 stay
Not Available
# ER visits, past year
None
One ER visit
More than 1 visit
Not Available
Coverage
Pharmacy assistance
No
Yes
Not Available
Heath care coverage
(Check all that apply)
No coverage
Medicare
Medicaid
IHS (Indian Health Service)
Private insurance
Other Government plan
Single service plan
Reduced-fee/sliding scale
Free care
Other
Specify:
Check all that apply
Asthma
__ __ / __ __ / __ __ __ __
Asthma, at risk/pre-asthma
Asthma, diagnosed
CHF
__ __ / __ __ / __ __ __ __
(Congestive Heart Failure)
CHF, diagnosed
CVD
__ __ / __ __ / __ __ __ __
(Cardiovascular Disease)
CVD, at risk/family history
CVD, diagnosed
Depression
__ __ / __ __ / __ __ __ __
Depression, positive screen
Depression, diagnosed
Diabetes
__ __ / __ __ / __ __ __ __
Diabetes, at risk/family history
Diabetes, pre-diabetes
Diabetes, diagnosed
Gestational diabetes
Hyperlipidemia __ __ / __ __ / __ __ __ __
Hyperlipidemia, diagnosed
Hypertension __ __ / __ __ / __ __ __ __
Hypertension, positive screen
Hypertension, diagnosed
Obesity
__ __ / __ __ / __ __ __ __
Obesity (adult)
Obesity (pediatric)
Other
Other
Specify:
__ __ / __ __ / __ __ __ __
Cancer
__ __ / __ __ / __ __ __ __
Type of cancer:
Cancer, screening
Cancer, abnormal finding
Cancer, diagnosed
Stage: 0 1 2 3
4
N/A
Entered: __ __ / __ __ / __ __ By: _______
Patient Navigator Outreach and Chronic Disease Prevention Program
Patient Intake Form (cancer only)
Study ID:
Enrollment Date:
Subsite:
Demographics
Household
Gender (Check one) *
Male
Female
Transgender
3-digit zip prefix
Birth year *
__ __ __
Household size
__ __ __ __
Ethnicity (Check one) *
Hispanic or Latino
Non-Hispanic
Race (Check all that apply)
White
Black/African American
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaska Native
Refused
Optional race coding:
Primary/preferred language *
(Check one)
English
Spanish
Chinese
Fijian
Filipino
Tagalog
French
Ilocano
Haitian Creole
Visayan
Hmong
Other
Japanese
Korean
Micronesian
Chuukese
Mixteco
Kosraean
Navajo
Marshalese
Samoan
Pohnpeian
Somali
Yapese
Tongan
Vietnamese
Other
Specify:
Rev. 14-Oct-2011
Navigated Condition(s)
Refused
Education (Check one)
No formal education
Primary education only
Some HS/secondary education
HS Diploma/GED/other secondary
education
Some college/vocational school/
other post-secondary education
Completed college, post-secondary
or vocational school
Post-college/graduate school
Refused
* Required for registration
Local Identifiers (site use only)
Navigator:
__ __
Cancer, screening
Cancer, abnormal finding
Cancer, diagnosed
Refused
(# in household, Including patient)
Household income (Check one)
Less than $10K
$10K to $19,999
$20K to $29,999
$30K to $39,999
$40K to $49,999
$50K or more
Refused
Utilization
# Hospital stays, past year
None
One stay
More than 1 stay
Not Available
Date:
__ __ / __ __ / __ __ __ __
Type of cancer:
Diagnosed cancer only
Stage:
0
1
2
Substage (optional):
3
A
4
B
N/A
C
TNM Staging (optional):
Histology(optional):
# ER visits, past year
None
One ER visit
More than 1 visit
Not Available
Coverage
Pharmacy assistance
No
Yes
Not Available
Heath care coverage
(Check all that apply)
No coverage
Medicare
Medicaid
IHS (Indian Health Service)
Private insurance
Other Government plan
Single service plan
Reduced-fee/sliding scale
Free care
Other
Specify:
Entered: __ __ / __ __ / __ __ By: _______
Patient Navigator Outreach and Chronic Disease Prevention Program
Navigation Target Form
Type of Service
Study Data
Navigator ID:
Date Identified:
Date Scheduled:
Notes
Medical visit for other conditions
Lab or diagnostic test
Primary care
Medical specialist (MD or DO)
Optional:
Unscheduled Service
Check one
Internal
External
Location Notes:
Status Options
Open target:
Scheduled
Rescheduled
Canceled
No show
Paperwork complete
Check one
Medical visit for cancer
Screening
Diagnostic test
Cancer treatment
Study ID:
Location
Local Identifiers (site use only)
Closed target:
Services received
Ineligible
Unable to access
No longer relevant
Refused
Health education
Certified diabetes educator
Nutritionist
Other health education/disease
management
Social services and assistance
Health care coverage
Pharmacy assistance
Medical equipment
Other service (Government agency)
Other service (nonprofit/charitable org)
Other services
Behavioral/mental health services
Clinical trials
Other
Specify:
Use the table below to record scheduling changes and/or target resolution.
Date
Rev. 20-Sep-2011
Status
Notes (optional)
Entered: __ __ / __ __ / __ __ By: _______
Navigation Target Form (page 2)
Use the table below to record scheduling changes and/or target resolution.
Date
Status
Notes (optional)
Notes:
Rev. 20-Sep-2011
Entered: __ __ / __ __ / __ __ By: _______
File Type | application/pdf |
File Title | Slide 1 |
Author | Carmita Signes |
File Modified | 2011-10-14 |
File Created | 2011-10-14 |