Quarterly Patient Information Form

Attachment 7b

Form Approved

OMB No: 0920-XXXX

Exp. Date: XX/XX/XXXX

QUARTERLY PATIENT INFORMATION FORM INSTRUCTIONS

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

QUARTERLY PATIENT INFORMATION FORM INSTRUCTIONS

Patient Project ID: Provide the unique Patient Project ID for whom this form is being completed.

Staff Project ID: Provide the unique Staff Project ID for the staff person completing this form.

Clinic Project ID: Provide the unique Clinic Project ID for the reporting clinic site.

Has there been any change to the patient’s or clinic’s contact information?

• Select the applicable response: “yes” or “no”

If yes, please complete the following table:

FOR PARTNERED SITE USE ONLY

PATIENT INFORMATION:

ADDRESS: Enter patient’s current street number and name, city, state, and zip code.

PHONE NUMBER: Enter the patient’s most current telephone number(s). Check the “mobile” box if the number is for the patient’s mobile phone. Check the “home” box if the number is for the patient’s home phone.

EMAIL ADDRESS: Enter the patient’s email address.

CLINIC INFORMATION:

PROVIDER NAME: Enter the first and last name of the provider who is most responsible for the medical management of the patient.

CLINIC NAME: Enter the name of the project clinic.

CLINIC NUMBER: Enter the area code and phone number of the clinic.

CLINIC FAX NUMBER: Enter the clinic fax number, including area code.

PRIMARY CLINIC CONTACT PERSON: Enter the first and last name of the primary clinic contact person who can be contacted to discuss patient care and supply additional information if needed.

CONTACT PHONE NUMBER: Enter the area code and telephone number for the primary clinic contact person

EMAIL ADDRESS: Enter the email address for the primary clinic contact person

SECONDARY CLINIC CONTACT PERSON: Enter the first and last name of the secondary clinic contact person who can be contacted to discuss patient care and supply additional information if needed.

CONTACT PHONE NUMBER: Enter the area code and telephone number for the secondary clinic contact person

EMAIL ADDRESS: Enter the email address for the secondary clinic contact person

DATE: Enter the date (MM/DD/YYYY) the Quarterly Patient Information form was completed.

Patient Project ID: Provide the unique Patient Project ID for whom this form is being completed.

Has patient had a medical visit with a physician, nurse practitioner or physician’s assistant since the last quarterly update?

• Select the applicable response: “yes” or “no”

If patient did not have medical visit with a physician, nurse practitioner or physician’s assistant since the last quarterly update, has the patient been seen in the clinic for any reason (e.g. case management, mental health) or had labs drawn in the past 6 months?

• Select the applicable response: “yes” or “no”

If no, state the reason why the patient is not continuing care or has not been seen in the clinic in the past 6 months

• Select the applicable response: “patient has missed scheduled appointments” or “patient died” or “patient too ill” or “moved out of area” or “transferred care to another provider” or “incarcerated” or “voluntary withdraw from project” or “don’t know/unsure what happened to patient” or “other”

• If “other” is selected, please provide a brief reason why patient has not been seen in the clinic in the past 6 months

  • Enter the date (MM/DD/YYYY) that the selected response occurred.

    • For example, if patient moved out of the area on July 2, 2015 select “moved out of area” and write 07/02/2015 for the date

  • If the date of the patient’s status for the selected response is unknown or not available, check “Unknown”.

*If patient has not been seen in the clinic for any reason AND has not had labs drawn in the past 6 months, STOP

• If the patient has not been seen in the clinic for any reason (e.g. medical visit, case management, mental health, substance abuse counseling, laboratory visit) AND has not had labs drawn in the past 6 months do not continue to complete the form

Patient Information

Has there been a change in the patient’s insurance status since the last quarterly update?

• Select the applicable response: “no” or “yes, patient has a new insurer” or “yes, patient is no longer insured”

• If a change in the patient’s insurance status is unknown, check “Unknown”.

If patient has a new insurer please provide the name of new insurer

• For patients who have changed insurers, provide the name of the new insurer

Most recent weight (lbs. /kg)

• Enter the patient’s most recent weight. Circle if weight was measured in pounds (lbs.) or kilograms (kg).

• Enter the date (MM/DD/YYYY) that the weight was measured.

Was patient’s blood pressure taken since the last quarterly update?

• Select the applicable response: “yes” or “no”

• If yes, enter each blood pressure value (systolic/diastolic) and date (MM/DD/YYYY) the blood pressure was measured, since the last quarterly update.

• Blood pressure values should be recorded with the following units: mmHg

I. Patient Lab Information

A. Please update lab information since the last quarterly update

All dates in this section should reflect the date that each lab test was drawn

If there are more than four labs values to be reported use the additional table at the end of the Quarterly Patient Information form (page xx).

CD4:

• Was lab drawn?: Check “yes” if a CD4 lab test was drawn, check “no” if no CD4 lab test was drawn.

• If a CD4 test was drawn, enter each absolute CD4 and % CD4 laboratory test result since the last quarterly update.

• The absolute CD4 test results should be recorded with the following units: cells/ μL

• The % CD4 test result should reflect the percentage of total lymphocytes that are CD4 cells.

• If both the absolute CD4 count and % CD4 are available, record both. If both are not available, enter the one test result that is available and leave the other blank.

• Enter the date (MM/DD/YYYY) each CD4 laboratory test was taken.

• If the CD4 lab test result is not available at the time the form is being completed, check “pending”.

HIV-1 RNA/DNA NAAT (Quantitative viral load):

• Was lab drawn?: Check “yes” if a HIV-1 RNA or DNA NAAT (Quantitative viral load) lab test was drawn, check “no” if no HIV-1 RNA or DNA NAAT (Quantitative viral load lab test was drawn.

• If a viral load test was drawn, enter each viral laboratory test result since the last quarterly update.

• The viral load test results should be recorded with the following units: copies/milliliter (mL).

• Enter the date (MM/DD/YYYY) each viral load test was taken.

• Viral load tests with undetectable results (based on the assay threshold) should also be entered here.

  • For example, for results with a value less than 48, record as <48 copies/mL.

• If the HIV-1 RNA or DNA NAAT lab test result is not available at the time the form is being completed, check “pending”.

B. Please update lab information since the last quarterly update

All dates in this section should reflect the date that each lab test was drawn

If there are more than four labs values to be reported use the additional table at the end of the Quarterly Patient Information form (page xx).

Total cholesterol

• Was lab drawn?: Check “yes” if a total cholesterol lab test was drawn, check “no” if no total cholesterol lab test was drawn.

• If a total cholesterol test was drawn, enter each total cholesterol laboratory test result since the last quarterly update.

• The total cholesterol test result should be recorded with the following units: mg/dl.

• Enter the date (MM/DD/YYYY) each total cholesterol test was taken.

• If the total cholesterol lab test result is not available at the time the form is being completed, check “pending”.

LDL

• Was lab drawn?: Check “yes” if a LDL (Low Density Lipoprotein) lab test was drawn, check “no” if no LDL lab test was drawn.

• If a LDL test was drawn, enter each LDL laboratory test result since the last quarterly update.

• The LDL lab result should be recorded with the following units: mg/dl.

• Enter the date (MM/DD/YYYY) each LDL test was taken.

• If the LDL lab test result is not available at the time the form is being completed, check “pending”.

HDL

• Was lab drawn?: Check “yes” if a HDL (High Density Lipoprotein) lab test was drawn, check “no” if no HDL lab test was drawn.

• If a HDL test was drawn, enter each HDL laboratory test result since the last quarterly update.

• The HDL laboratory result should be recorded with the following units: mg/dl.

• Enter the date (MM/DD/YYYY) each HDL test was taken.

• If the HDL lab test result is not available at the time the form is being completed, check “pending”.

TG (triglyceride)

• Was lab drawn?: Check “yes” if a TG (triglyceride) lab test was drawn, check “no” if no TG lab test was drawn.

• If a TG test was drawn, enter each TG laboratory test result since the last quarterly update.

• The TG laboratory result should be recorded with the following units: mg/dl.

• Enter the date (MM/DD/YYYY) each TG test was taken.

• If the TG lab test result is not available at the time the form is being completed, check “pending”.

HbA1c

• Complete for patients with diabetes.

• Was lab drawn?: Check “yes” if a HbA1c (Hemoglobin A1c) lab test was drawn, check “no” if no HbA1c lab test was drawn.

• If a HbA1c test was drawn, enter each HbA1c laboratory test result since the last quarterly update.

• The HbA1c laboratory test result should be recorded with the following units: %.

• Enter the date (MM/DD/YYYY) each HbA1c test was taken.

• If the HbA1c lab test result is not available at the time the form is being completed, check “pending”.

Glucose

• Was lab drawn?: Check “yes” if a glucose lab test was drawn, check “no” if no glucose lab test was drawn.

• If a glucose test was drawn, enter each glucose laboratory test result since the last quarterly update.

• If patient was fasting circle Y (yes) or circle N (no) if patient was not fasting. If information is not available about whether the patient was fasting, circle UNK (unknown).

• The glucose laboratory test result should be recorded with the following units: mg/dl.

• Enter the date (MM/DD/YYYY) each glucose test was taken.

• If the glucose lab test result is not available at the time the form is being completed, check “pending”.

Hemoglobin

• Was lab drawn?: Check “yes” if a hemoglobin test was drawn, check “no” if no hemoglobin lab test was drawn.

• If a hemoglobin test was drawn, enter each hemoglobin test result since the last quarterly update.

• The hemoglobin laboratory result should be recorded with the following units: g/dL

• Enter the date (MM/DD/YYYY) each hemoglobin test was taken.

• If the hemoglobin test result is not available at the time the form is being completed, check “pending”.

LFTs (Liver function tests)

• Was lab drawn?: Check “yes” if a LFT (Liver Function Tests) lab test was drawn, check “no” if no LFT lab test was drawn.

• If a LFT test was drawn, enter each ALT (alanine transaminase) and AST (aspartate transaminase) laboratory test result since the last quarterly update.

• The ALT and AST laboratory result should be recorded with the following units: units/L.

• Enter the date (MM/DD/YYYY) each LFT test was taken.

• If the LFTs lab test result is not available at the time the form is being completed, check “pending”.

Bilirubin

• Was lab drawn?: Check “yes” if a bilirubin lab test was drawn, check “no” if no bilirubin lab test was drawn.

• If a bilirubin test was drawn, enter each bilirubin laboratory test result since the last quarterly update.

• The bilirubin test result should be recorded with the following units: mg/dL.

• Enter the date (MM/DD/YYYY) each bilirubin test was taken.

• If the bilirubin lab test result is not available at the time the form is being completed, check “pending”.

Creatinine

• Was lab drawn?: Check “yes” if a serum creatinine lab test was drawn, check “no” if no serum creatinine lab test was drawn.

• If a serum creatinine test was drawn, enter each srum creatinine laboratory test result since the last quarterly update.

• The serum creatinine laboratory result should be recorded with the following units: mg/dl.

• Enter the date (MM/DD/YYYY) each serum creatinine test was taken.

• If the serum creatinine lab test result is not available at the time the form is being completed, check “pending”.

Urinalysis

• Was lab drawn?: Check “yes” if an urinalysis was done, check “no” if no urinalysis was done.

• If an urinalysis test was done since the last quarterly update, circle “+ protein” if protein was found in urine or “– protein” if no protein was found in the urine.

  • If trace protein was found in urine, circle “+ protein”

• Enter the date (MM/DD/YYYY) each urinalysis test was done

• If the urinalysis lab test result is not available at the time the form is being completed, check “pending”.

Basic Chemistry Panel

• If a basic chemistry panel was completed since the last quarterly update, circle Y (yes) or circle N (no) if no basic chemistry panel was completed

  • A basic chemistry panel refers to 7 common laboratory tests including sodium, potassium, chloride bicarbonate, blood urea nitrogen, creatinine and glucose.

  • If the above mentioned tests were completed ,since the last quarterly update, circle Y (yes)

• If a basic chemistry panel was done, enter the date (MM/DD/YYYY) each basic chemistry panel was completed.

• If the basic chemistry panel results are not available at the time the form is being completed, check “pending”.

HBV DNA

• Complete for patients co-infected with HBV (hepatitis B virus).

• Was lab drawn?: Check “yes” if an HBV DNA (hepatitis B DNA) lab test was drawn, check “no” if no HBV DNA lab test was drawn.

• If an HBV DNA test was drawn, enter each HBV DNA laboratory test result since the last quarterly update.

• The HBV DNA test result should be recorded with the following units: copies/mL.

• Enter the date (MM/DD/YYYY) each HBV DNA test was taken.

• If the HBV DNA lab test result is not available at the time the form is being completed, check “pending”.

HCV RNA

• Complete for patients co-infected with HCV (hepatitis C virus).

• Was lab drawn?: Check “yes” if an HCV RNA (hepatitis C RNA) lab test was drawn, check “no” if no HCV RNA lab test was drawn.

• If an HCV RNA test was drawn, enter each HCV RNA laboratory test result since the last quarterly update.

• The HCV RNA test result should be recorded with the following units: copies/mL.

• Enter the date (MM/DD/YYYY) each HCV RNA test was taken.

• If the HCV RNA lab test result is not available at the time the form is being completed, check “pending”.

Syphilis

• Was lab drawn?: Check “yes” if syphilis screening was done, check “no” if no syphilis screening was done.

• If syphilis screening was done, select if the result was “negative” or “positive” for each test result since the last quarterly update.

• Enter the date (MM/DD/YYYY) each Syphilis test was taken.

• If the Syphilis lab test result is not available at the time the form is being completed, check “pending”.

C. Please provide the following information on viral hepatitis testing since the last quarterly update:

Was the patient tested for HBsAg (Hepatitis B surface antigen) since the last quarterly update?

• Select the applicable response: “yes” or “no”

• If it is unknown if patient was tested for HBsAg, check “Unknown”.

• If patient was tested for HBsAg ,since the last quarterly update, select if the result was negative or positive.

Was the patient tested for anti-HBs (antibody to Hepatitis B surface antigen) since the last quarterly update?

• Select the applicable response: “yes” or “no”

• If it is unknown if patient was tested for anti-HBs, check “Unknown”.

• If patient was tested for anti-HBs ,since the last quarterly update, select if result was >10 mlU/mL (positive) or <10 mlU/mL (negative).

Was the patient tested for anti-HCV (antibody to Hepatitis C virus) since the last quarterly update?

• Select the applicable response: “yes” or “no”

• If it is unknown if patient was tested for anti-HCV, check “Unknown”.

• If patient was tested for anti-HCV ,since the last quarterly update, select if the result was negative or positive.

If anti-HCV test was positive, was a confirmatory test done?

• Select the applicable response: “yes” or “no”

  • Hepatitis C confirmatory tests include recombinant immunoblot assay (RIBA) and hepatitis C RNA tests

• If it is unknown if a confirmatory test was done, check “Unknown”.

• If patient had a conformatory test for hepatitis C ,since the last quarterly update, select if the result was negative or positive.

II. Medication Updates

FOR ALL DATES, if the exact date is not known, provide as much information as possible. For example, if the day is unknown but the month and year are known, provide the month (MM) and year (YYYY).

A1. Please list all antiretroviral therapy (ART) medications that the patient CURRENTLY takes (at the time of quarterly update)

NAME OF CURRENT ART MEDICATIONS:

• List the name(s) of ALL ART medications the patient is currently taking.

• Fixed dose combination medications, such as Atripla, should be listed on one line.

DOSAGE (mg):

• List the dosage (mg) of each current ART medication.

• Fixed dose combination medications, such as Atripla, should be listed on one line.

• For fixed dose combination medications, such as Atripla, the dosage (mg) of each component should be separated by a “/”. For example, Atripla 600/200/300 .

FREQUENCY:

• List the prescribed frequency for the ART medication (e.g. once daily, three times per day)

• Do not use abbreviations (e.g. qd for once daily). Instead, fully write out the prescribed frequency (e.g. twice daily)

START DATE:

• List the date (MM/DD/YYYY) the patient’s provider started the patient on each medication

Example:

Name of Current ART Medications*	Dosage (mg)	Frequency	Prescription start date
Atripla	600/200/300	Once daily	01/15/2013

Have there been any changes to the patient’s ART since last quarterly update?

• Select the applicable response: “yes” or “no”

Has an HLA-B*5701 test been done?

• Select the applicable response: “yes” or “no”

If yes, what was the result of the HLA-B*5701 test?

• Select the applicable response: “negative” or “positive”

Has a tropism assay been done?

• Select the applicable response: “yes” or “no”

If yes, what were the results?

• Select the applicable response: “CCR5 positive” or “CXCR4 positive” or “dual or mixed tropism”

A2. List all NEW ART medications initiated since last quarterly update

NAME OF NEW ART MEDICATIONS:

• List the name(s) of all NEW ART medications prescribed since the last quarterly update

• Fixed dose combination medications, such as Atripla, should be listed on one line.

• If a patient has been prescribed a new ART medication since the last quarterly update that was also discontinued during the same time period, list the medication in both Tables A1 (new ART medications) and A2 (discontinued ART medications)

DOSAGE (mg):

• List the dosage (mg) of each NEW ART medication.

• Fixed dose combination medications, such as Atripla, should be listed on one line.

• For fixed dose combination medications, such as Atripla, the dosage (mg) of each component should be separated by a “/”. For example, Atripla 600/200/300 .

FREQUENCY:

• List the prescribed frequency for the ART medication (e.g. once daily, three times per day)

• Do not use abbreviations (e.g. qd for once daily). Instead, fully write out the prescribed frequency (e.g. twice daily)

START DATE:

• List the date (MM/DD/YYYY) the patient’s provider started the patient on each NEW medication

Example

Name of new ART medication	Dosage (mg)	Frequency	Start date
Tenofovir	300	once daily	08/11/2012

A3. List all discontinued ART medications since last quarterly update

NAME OF ALL DISCONTINUED ART MEDICATION:

• List the name(s) of ALL ART medications discontinued since the last quarterly update.

• Fixed dose combination medications, such as Atripla, should be listed on one line.

• If a patient has been prescribed a new ART medication since the last quarterly update that was also discontinued during the same time period, list the medication in both Tables A1 (new ART medications) and A2 (discontinued ART medications)

DATE DISCONTINUED:

• List the date (MM/DD/YYYY) the ART medication was discontinued.

REASON FOR DISCONTINUATION:

• Select the applicable response for why medication was discontinued: “tolerability” or “toxicity/side effects” or “failure” or “other”

• If “other” is selected, provide a brief reason as to why the medication was discontinued

Example:

Name of discontinued ART Medication	Date discontinued	Reason for discontinuation
Lamivudine	06/23/2009	□ tolerability X toxicity / side effects □ failure □ other ___________

B1. Please list all other medications that the patient currently takes (at the time of quarterly update)

NAMES OF OTHER CURRENT MEDICATIONS:

• List the name(s) of ALL other current medications the patient is taking at the time of the quarterly update

  • This includes all medications for other chronic and/or acute conditions.

  • This also includes non-prescription medications such as over-the-counter- medications, herbal products and supplements

DOSAGE (mg)

• Provide the dosage (mg) of each listed medication.

• For fixed dose combination medications the dosage (mg) of each component should be separated by a “/”. For example, Bactrim 800/160 .

• If a patient is prescribed a medication with two separate doses, please list each dose on a separate line

FREQUENCY

• Provide the prescribed frequency for each listed medication.

• Do not use abbreviations (e.g. qd for once daily). Instead, fully write out the prescribed frequency (e.g. twice daily)

START DATE

• Provide the start date (MM/DD/YYYY) for each listed medication.

Example:

Names of Other Current Medications	Dosage (mg)	Frequency	Start date
Metformin	1000	Twice daily	05/21/2000
Metformin	500	Once daily	05/21/2000

Have there been any changes to the patient’s other medications (non-HIV medications) since last quarterly update?

• Select the applicable response: “yes” or “no”

B2. List all NEW non-HIV medications initiated since last quarterly update

NAME OF NEW non-HIV MEDICATIONS:

• List the name(s) of all NEW non-HIV medications prescribed since the last quarterly update

  • This includes all medications for other chronic and/or acute conditions.

  • This also includes non-prescription medications such as over-the-counter- medications, herbal products and supplements

• If a patient has been prescribed a new medication since the last quarterly update that was also discontinued during the same time period, list the medication in both Tables B1 and B2 (discontinued medications)

DOSAGE (mg)

• Provide the dosage (mg) of each listed medication.

• For fixed dose combination medications the dosage (mg) of each component should be separated by a “/”. For example, Bactrim 800/160 .

• If a patient is prescribed a medication with two separate doses, please list each dose on a separate line

FREQUENCY

• Provide the prescribed frequency for each listed medication.

• Do not use abbreviations (e.g. qd for once daily). Instead, fully write out the prescribed frequency (e.g. twice daily)

REASON FOR INITIATION

• Provide a brief reason for initiation of the non-HIV medication

START DATE

• Provide the start date (MM/DD/YYYY) for each listed medication.

Example:

Name of new non-HIV medication	Dosage (mg)	Frequency	Reason for Initiation	Start date
Lisinopril	10	Twice daily	hypertension	10/28/2013
Bactrim DS	800/160	Twice daily	Urinary tract infection	11/15/2013

B3. List all discontinued non-HIV medications since last quarterly update

NAME OF DISCONTINUED non-HIV MEDICATION:

• List the name(s) of all non-HIV medications discontinued since the last quarterly update.

• If a patient has been prescribed a new medication since the last quarterly update that was also discontinued during the same time period, list the medication in both Tables B1 (new non-HIV medications) and B2 (discontinued non-HIV medications)

DATE DISCONTINUED:

• List the date (MM/DD/YYYY) the non-HIV medication was discontinued

REASON FOR DISCONTINUATION:

• Select the applicable response for why medication was discontinued: “tolerability” or “toxicity/side effects” or “failure” or “no longer indicated” or “other”

• If “other” is selected, provide a brief reason as to why the medication was discontinued

Name of discontinued ART Medication	Date discontinued	Reason for discontinuation
Prilosec	09/14/2013	□ tolerability □ toxicity / side effects □ failure X no longer indicated □ other __________

III. Medical History and Allergies Updates

_{A. Were there any newly diagnosed medical conditions or problems at any time since the last quarterly update?}

• Select the applicable response: “yes” or “no”

If yes, list all newly diagnosed medical conditions and problems in the Table.

• NEWLY DIAGNOSED MEDICAL CONDITIONS OR NEW MEDICAL PROBLEMS: list any new medical conditions or problems that began since last quarterly update

  • If a new medication was prescribed to treat this new condition, please ensure that the new medication is added to the new non-HIV medication table (section II, table B1)

• DATE DIAGNOSED: Enter the date (MM/DD/YYYY) each new medical condition or problem was diagnosed.

_{B. Were there any resolved medical problems at any time since the last quarterly visit?}

• Select the applicable response: “yes” or “no”

If yes, list all resolved medical problems in the Table.

• RESOLVED MEDICAL PROBLEM: list any medical problems that have resolved since the last quarterly update

• DATE RESOLVED: Enter the date (MM/DD/YYYY) each medical problem resolved.

C. Were there any newly diagnosed drug allergies since the last quarterly update?

• Select the applicable response: “yes” or “no”

If yes, list all new drug allergies in the Table.

• NAME OF MEDICATION: list the name of the medication to which the patient is allergic

• REACTION TO MEDICATION: list the reaction that patient has to the medication

• DATE ALLERGY DEVELOPED: enter the date (MM/DD/YYYY) that the allergy developed

IV. Tobacco, Drug and Alcohol Use

Has patient’s smoking status changed since last quarterly update?

• Select the applicable response: “yes” or “no”

• If patient’s smoking status is unknown, check “Unknown”

If yes, how has smoking status changed?

• Select the applicable response: “increased amount smoked” or “decreased amount smoked” or “new smoker” or “quit smoking”

• If patient’s smoking status hasn’t changed since last quarterly update, check “N/A”

• If the patient is a new smoker ,since the last quarterly update, enter the date (MM/DD/YYYY) that the patient began smoking

• If the patient has quit smoking ,since the last quarterly update, enter the date (MM/DD/YYYY) that the patient quit smoking

Has patient’s illegal drug use/abuse of prescription controlled substances changed since last quarterly update?

• Select the applicable response: “yes” or “no”

• If patient’s drug use/abuse status is unknown, check “Unknown”

If yes, how has drug abuse status changed?

• Select the applicable response: “increased amount used” or “decreased amount used” or “new user” or “quit using”

• If patient has never used illegal drugs or abused controlled prescription drugs, check “N/A”

• If the patient is a new drug abuser ,since the last quarterly update, enter the date (MM/DD/YYYY) that the patient began abusing drugs

• If the patient has quit abusing drugs ,since the last quarterly update, enter the date (MM/DD/YYYY) that the patient quit abusing drugs

Has patient initiated or completed substance abuse treatment since last quarterly update?

• Select the applicable response: “yes, currently in a program” or “yes, completed a program” or “no”

• If patient has never had a substance abuse problem, check “N/A”

• If whether the patient has initiated or completed a substance abuse treatment program ,since the last quarterly update, is not known, check “Unknown”

Has patient’s heavy alcohol consumption changed since last quarterly update?

• Select the applicable response: “yes” or “no”

• If patient’s alcohol consumption is unknown, check “Unknown”

If yes, how has alcohol consumption changed?

• Select the applicable response: “increased drinking” or “decreased drinking” or “new heavy drinker” or “quit drinking”

• If patient’s alcohol consumption hasn’t changed since last quarterly update, check “N/A”

• If the patient is a new heavy drinker since the last quarterly update, enter the date (MM/DD/YYYY) that the patient began drinking heavily

  • Heavy alcohol consumption for males equals ≥5 drinks on any single day or ≥15 drinks per week; for women heavy alcohol consumption equals ≥4 drinks on any single day or ≥8 drinks per week

• If the patient has quit drinking alcohol, since the last quarterly update, enter the date (MM/DD/YYYY) that the patient became abstinent

Has patient initiated or completed alcohol abuse treatment since last quarterly update?

• Select the applicable response: “yes, currently in a program” or “yes, completed a program” or “no”

• If patient has never had a alcohol abuse problem, check “N/A”

• If whether the patient has initiated or completed an alcohol abuse treatment program, since the last quarterly update, is not known, check “Unknown”

V. Immunization History

Did client receive any immunizations at this clinic since last quarterly update?

• Select the applicable response: “yes” or “no”

• If yes, list which immunization(s) was provided.

• Enter the date (MM/DD/YYYY) the immunization was provided.

VI. Clinic Appointment Information

Was patient scheduled for any appointments (e.g. medical, case management, mental health, substance abuse) since last quarterly update?

• Select the applicable response: “yes” or “no” or “unknown”

If yes, please list ALL appointments (medical, case management, mental health, substance abuse) scheduled for the patient since the last quarterly update and note if appointment was kept

Each box should include 3 pieces of information: 1) type of scheduled appointment (medical visit, case management, mental health, substance abuse) 2) the date of the appointment and 3) whether the appointment was kept by the patient

• Use one box for each appointment.

• Select the applicable response for type of appointment

  • A medical visit would be selected if a patient was seen by a physician, nurse practitioner or physician’s assistant

  • Appointments for case management may include appointments with a social worker

• Enter the date (MM/DD/YYYY) of the appointment

• Select “yes” if the patient kept the appointment or “no” if the patient did not keep the appointment. If it is unknown if the patient kept the appointment, check “Unknown”

• If there are more than 12 clinic appointments to be reported use the additional table at the end of the Quarterly Patient Information form (page xx).

Example:

Type of appointment Date Was appt. kept?	Type of appointment Date Was appt. kept?
Medical visit* X _09_/_13__/2013_ X yes □ no Case management† □ Unknown Mental Health □ Substance Abuse □	Medical visit* □ _11/29 /2013_ □ yes X no Case management □ □ Unknown Mental Health X Substance Abuse □

VII. Medication Therapy Management (MTM)

Was documentation of patient’s MTM visit(s) received by the clinic?

• Select the applicable response: “yes” or “no”

If yes, complete the following table for each MTM communication received since last quarterly update:

DATE MTM INFORMATION RECEIVED AT CLINIC

• Enter the date (MM/DD/YYYY) that information on patient’s MTM visit(s) was received by the clinic

HOW MTM INFORMATION WAS SENT TO CLINIC

• Select the applicable response: “fax” or “in person” or “other”

• If “other” is selected, provide a brief description of how MTM information was sent to the clinic

DID PROVIDER ACKNOWLEDGE RECEIPT OF MTM INFORMATION

• Select the applicable response: “yes” or “no” or “unknown”

• If yes, enter the date (MM/DD/YYYY) that the provider acknowledged receipt of the MTM information

VIII. Follow-up

When is patient’s next scheduled medical visit appointment with a physician, nurse practitioner or physician assistant?

• Enter the date (MM/DD/YYYY) of patient’s next scheduled appointment with a physician, nurse practitioner or physician assistant.

• If no appointment has been scheduled, check “no appointment scheduled”.

When is patient’s next scheduled Medication Therapy Management (MTM) appointment?

• Enter the date (MM/DD/YYYY) of patient’s next scheduled MTM (Medication Management Therapy) appointment.

• If no MTM appointment has been scheduled, check “no appointment scheduled”.

NOTES: (Provide additional information if needed)

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