COMPREHENSIVE CLIENT ASSESSMENT
Only use arrow down/up keys to navigate. Do not use tab key.MDHHS-6002, HIV CASE MANAGEMENT BIOPSYCHOSOCIAL ASSESSMENTMichigan Department of Health and Human Services (MDHHS)(New 6-22)SECTION 1 – CLIENT INFORMATIONFull Legal Name FORMTEXT ? FORMTEXT ?????Preferred Name FORMTEXT ?????Date of Birth FORMTEXT ?????Sex assigned at birth FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Other FORMTEXT ?????Current Gender FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Transgender FORMCHECKBOX Male to Female FORMCHECKBOX Female to Male FORMCHECKBOX Other FORMCHECKBOX Refuse to Report FORMCHECKBOX UnknownPreferred Gender Pronouns FORMTEXT ?????Ethnicity FORMCHECKBOX Hispanic FORMCHECKBOX Non-HispanicRace FORMCHECKBOX Black or African American FORMCHECKBOX White FORMCHECKBOX Asian FORMCHECKBOX Other FORMCHECKBOX Indian or Alaskan Native FORMCHECKBOX Native Hawaiian FORMCHECKBOX Pacific IslanderStreet Address FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip Code FORMTEXT ?????Send mail to this address? FORMCHECKBOX Yes FORMCHECKBOX NoConfidential mail required? FORMCHECKBOX Yes FORMCHECKBOX NoMailing Address (if different from above) FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip Code FORMTEXT ?????Send mail to this address? FORMCHECKBOX Yes FORMCHECKBOX NoConfidential mail required? FORMCHECKBOX Yes FORMCHECKBOX NoHome Phone Number FORMTEXT ?????Leave a message? FORMCHECKBOX Yes FORMCHECKBOX NoSend text? FORMCHECKBOX Yes FORMCHECKBOX NoConfidential message? FORMCHECKBOX Yes FORMCHECKBOX NoCell Phone Number FORMTEXT ?????Leave a message? FORMCHECKBOX Yes FORMCHECKBOX NoSend text? FORMCHECKBOX Yes FORMCHECKBOX NoConfidential message? FORMCHECKBOX Yes FORMCHECKBOX NoAlternative Phone Number FORMTEXT ?????Leave a message? FORMCHECKBOX Yes FORMCHECKBOX NoSend text? FORMCHECKBOX Yes FORMCHECKBOX NoConfidential message? FORMCHECKBOX Yes FORMCHECKBOX NoEmail Address FORMTEXT ?????Send email to this address? FORMCHECKBOX Yes FORMCHECKBOX NoConfidential message? FORMCHECKBOX Yes FORMCHECKBOX NoMarital Status FORMCHECKBOX Single FORMCHECKBOX Partnered FORMCHECKBOX Married FORMCHECKBOX Separated FORMCHECKBOX Divorced FORMCHECKBOX Widowedsection 2 – emergency contact informationSee Release of Information form to view emergency contact information.section 3 - transportationHow do you get to your healthcare appointments? FORMTEXT ? FORMTEXT ?????What barriers are there with transportation? FORMTEXT ?????Do you have disabilities that impact your access to transportation? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, what disability? FORMTEXT ?????Comments FORMTEXT ?????Needs Referral FORMCHECKBOX Yes FORMCHECKBOX Nosection 4 – housingDescribe your housing situation. FORMTEXT ? FORMTEXT ?????Type of Housing FORMCHECKBOX Stable FORMCHECKBOX Temporary FORMCHECKBOX UnstableHousing FORMCHECKBOX Rental FORMCHECKBOX Own home FORMCHECKBOX Transitional living facility FORMCHECKBOX Living on streets FORMCHECKBOX Shelter FORMCHECKBOX Hospital FORMCHECKBOX Nursing home FORMCHECKBOX Living with others FORMCHECKBOX Living in car FORMCHECKBOX Prison/jail FORMCHECKBOX Other FORMTEXT ?????Comments FORMTEXT ?????section 5 – finances and benefitsIncomeDescribe your income. FORMTEXT ? FORMTEXT ????? FORMCHECKBOX See Intake FormMonthly IncomeYes or NoCommentsEmployment/wages FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Unemployment FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Alimony/child support FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Pension or retirement income FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Social Security Retirement FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Worker’s compensation FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Social Security Disability Income FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Supplemental Security Income FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????FIP/TANF FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????State Disability Assistance FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Comments FORMTEXT ?????InsuranceDescribe your insurance. FORMTEXT ? FORMTEXT ????? FORMCHECKBOX See Intake FormIf no insurance, have you applied? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, which insurance? FORMTEXT ?????Benefit Type FORMTEXT ? FORMCHECKBOX Indian Health Services FORMCHECKBOX Medicaid FORMCHECKBOX Medicare FORMCHECKBOX Unspecified FORMCHECKBOX Part A FORMCHECKBOX Part B FORMCHECKBOX Part C FORMCHECKBOX Part D FORMCHECKBOX VA, Military, TRICARE FORMCHECKBOX Private Health Plan FORMCHECKBOX Healthy MI PlanADDITIONAL COVERAGE FORMCHECKBOX AIDS Drug Assistance Program FORMCHECKBOX Insurance Assistance Program FORMCHECKBOX Michigan Dental ProgramSee Release of Records for Provider InformationDoes the client need assistance with health insurance? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, explain FORMTEXT ?????Comments FORMTEXT ?????section 6 – mdhhs officeMDHHS Worker Name FORMTEXT ? FORMTEXT ?????MDHHS Worker Phone Number FORMTEXT ?????MDHHS Office Address FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip Code FORMTEXT ?????Outstanding MDHHS Needs FORMTEXT ?????section 7 – legalDo you need any legal assistance? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, need referral? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, explain FORMTEXT ?????Comments FORMTEXT ?????section 8 – cultural/linguisticsWhat is your preferred language? FORMTEXT ? FORMTEXT ????? FORMCHECKBOX Speak FORMCHECKBOX Read FORMCHECKBOX Write FORMCHECKBOX See Intake FormDo you need a translator or interpreter? FORMCHECKBOX Yes FORMCHECKBOX NoAre you deaf or hard of hearing? FORMCHECKBOX Yes FORMCHECKBOX NoDo you need a sign interpreter? FORMCHECKBOX Yes FORMCHECKBOX NoAre you able to complete forms independently? FORMCHECKBOX Yes FORMCHECKBOX NoDo you prefer a medical provider of a particular gender? FORMCHECKBOX Yes FORMCHECKBOX NoComments FORMTEXT ?????section 9 – health and medical careMedical AppointmentsAre you in medical care? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, complete the chart below.If no, needs referral? FORMCHECKBOX Yes FORMCHECKBOX NoType of ProviderNameClinic Name/Address/ Phone NumberLast AppointmentPrimary Care FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Infectious Disease FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do you schedule your own appointments? FORMCHECKBOX Yes FORMCHECKBOX NoWhat are some reasons for missed appointments? FORMTEXT ?????How do you keep track of medical visits, discussions about health, labs, etc.? FORMTEXT ?????How is your relationship with your medical provider? (Identify barriers related to provider-client relationship, clinic practices and services, etc.) FORMTEXT ?????Describe what you feel uncomfortable discussing with your medical provider. FORMTEXT ?????Comments FORMTEXT ?????Health StatusDate of HIV diagnosis FORMTEXT ? FORMTEXT ?????Mode of transmission/Risk Factors FORMCHECKBOX Male who has sex with male FORMCHECKBOX Injection drug use FORMCHECKBOX Hemophilia/Coagulation Disorder FORMCHECKBOX Heterosexual contact FORMCHECKBOX Perinatal FORMCHECKBOX Receipt of blood products, blood components or tissue FORMCHECKBOX Not Reported FORMCHECKBOX Not IdentifiedHIV Status FORMCHECKBOX HIV Positive, not AIDS FORMCHECKBOX HIV Positive, AIDS Status Unknown FORMCHECKBOX CDC Defined AIDS FORMCHECKBOX HIV Negative (Affected) FORMCHECKBOX HIV IndeterminateDescribe your health. (Discuss if health has improved/stayed same/declined; any significant changes in lab work; any concerns with health; if medications are working.) FORMTEXT ?????Viral Load FORMTEXT ?????Date FORMTEXT ?????CD4 count FORMTEXT ?????Date FORMTEXT ?????Women’s HealthAre you pregnant? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoAre you receiving prenatal care? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently breastfeeding? FORMCHECKBOX Yes FORMCHECKBOX NoComments FORMTEXT ?????Transgender HealthDo you have any transgender health needs? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoComments FORMTEXT ?????Oral HealthDescribe your dental healthcare needs. FORMTEXT ? FORMTEXT ?????Needs Referral FORMCHECKBOX Yes FORMCHECKBOX NoIdentified Barriers FORMTEXT ?????Comments FORMTEXT ?????Vision HealthDescribe your vision healthcare needs. FORMTEXT ? FORMTEXT ?????Needs Referral FORMCHECKBOX Yes FORMCHECKBOX NoIdentified Barriers FORMTEXT ?????Comments FORMTEXT ?????Medication AdherenceDescribe how you take your medications. FORMTEXT ? FORMTEXT ?????Have you missed any doses in the last month and if so, why? FORMTEXT ?????What will make it easier for you to take your medications when missing doses? FORMTEXT ?????What side effects are you experiencing with your HIV medications? FORMTEXT ?????If you are having side effects, what did your provider tell you about the side effects you’re having? FORMTEXT ?????How do you receive your medications? FORMCHECKBOX Pick up at pharmacy FORMCHECKBOX Delivery FORMCHECKBOX Other FORMTEXT ?????Do you have difficulty filling/refilling your medications? FORMCHECKBOX Yes FORMCHECKBOX NoWhere do you store your medications? FORMTEXT ?????Do you believe your medications are stored safely? FORMCHECKBOX Yes FORMCHECKBOX NoDo you hide your medications from others? FORMCHECKBOX Yes FORMCHECKBOX NoHow do you take your medications? FORMCHECKBOX Given by another person FORMCHECKBOX Self-administered FORMCHECKBOX Other FORMTEXT ?????Name of Primary Pharmacy FORMTEXT ?????Name of Secondary Pharmacy FORMTEXT ?????Are you having trouble with any of the following? FORMCHECKBOX Understanding instructions for medications FORMCHECKBOX Not taking proper number of medications FORMCHECKBOX Taking medications prescribed for others FORMCHECKBOX Not taking medications on timeComments FORMTEXT ?????HIV MedicationsName of MedicationDosePrescriber (if applicable) FORMTEXT ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Food and NutritionDo you have access to food? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoNeeds Referral FORMCHECKBOX Yes FORMCHECKBOX NoComments FORMTEXT ?????Activities of Daily LivingDo you need assistance with daily living activities? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoNeeds Referral FORMCHECKBOX Yes FORMCHECKBOX NoComments FORMTEXT ?????Mental Health/Substance UseDescribe your current or history of mental health diagnoses or needs (depression, anxiety, bi-polar, etc.). FORMTEXT ? FORMTEXT ?????Needs Referral FORMCHECKBOX Yes FORMCHECKBOX NoIf needed, see assessment tool in the attachments (Stress questionnaire)Describe your current or history of substance use (street drugs, prescription drugs, alcohol, etc.). FORMTEXT ?????Needs Referral FORMCHECKBOX Yes FORMCHECKBOX NoComments FORMTEXT ?????Tobacco UseDescribe any current or history of tobacco product use (cigarettes, chewing tobacco, e-cigs, etc.). FORMTEXT ? FORMTEXT ?????Needs Referral FORMCHECKBOX Yes FORMCHECKBOX NoComments FORMTEXT ?????Section 10 – hiv knowledge and health literacyHow much education have you received about HIV and transmission of HIV? FORMTEXT ? FORMTEXT ?????Based on the above information, rate the client’s level of HIV knowledge. FORMCHECKBOX Excellent FORMCHECKBOX Very Good FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorDo you need help with the following:Figuring out the time to take medications? FORMCHECKBOX Yes FORMCHECKBOX NoFiguring out if you need to eat with medications? FORMCHECKBOX Yes FORMCHECKBOX NoUnderstanding your medical provider when he/she talks about your health? FORMCHECKBOX Yes FORMCHECKBOX NoBeing able to effectively communicate your needs to your medical provider? FORMCHECKBOX Yes FORMCHECKBOX NoBeing able to effectively negotiate your health? FORMCHECKBOX Yes FORMCHECKBOX NoDiscussing your insurance with your clinic’s billing office? FORMCHECKBOX Yes FORMCHECKBOX NoDiscussing your benefits with your insurance plan? FORMCHECKBOX Yes FORMCHECKBOX NoFilling out your medical forms by yourself? FORMCHECKBOX Yes FORMCHECKBOX NoComments FORMTEXT ?????section 11 – hiv prevention and risk reductionAre you sexually active? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoDescribe how you practice safer sex. FORMCHECKBOX Condom FORMCHECKBOX Dental dam FORMCHECKBOX Saran Wrap FORMCHECKBOX Latex gloves FORMCHECKBOX Withdrawal FORMCHECKBOX U=U FORMCHECKBOX Other: FORMTEXT ?????Do you have access to safe sex supplies? FORMCHECKBOX Yes FORMCHECKBOX NoNeeds Referral FORMCHECKBOX Yes FORMCHECKBOX NoAre there times when you do not practice safe sex? FORMCHECKBOX When I am sexually excited FORMCHECKBOX When I feel angry or upset FORMCHECKBOX When I am with a new partner FORMCHECKBOX When I am the top FORMCHECKBOX When I am the bottom FORMCHECKBOX When I am drinking and/or high FORMCHECKBOX When I feel bad about myself FORMCHECKBOX Condoms don’t feel good FORMCHECKBOX When I am seeking drugs/money FORMCHECKBOX When there’s not much risk FORMCHECKBOX When I am undetectable FORMCHECKBOX When I am not expecting sex FORMCHECKBOX When my partner pressures FORMCHECKBOX When my partner(s) are FORMCHECKBOX Other:me not to use condomsHIV-positive FORMTEXT ?????Comments FORMTEXT ?????Describe what you know about the Michigan HIV disclosure law. FORMTEXT ????? FORMCHECKBOX is aware FORMCHECKBOX needs more information/information provided FORMCHECKBOX Other FORMTEXT ?????Describe what you have heard about Undetectable equals Un-transmittable (U=U). FORMTEXT ????? FORMCHECKBOX is aware FORMCHECKBOX needs more information/information provided FORMCHECKBOX Other FORMTEXT ?????Describe what you know about Pre-exposure Prophylaxis (PrEP). FORMTEXT ????? FORMCHECKBOX is aware FORMCHECKBOX needs more information/information provided FORMCHECKBOX Other FORMTEXT ?????Are there any topics around sexual health or risk reduction you want to discuss or talk about? FORMTEXT ?????Comments FORMTEXT ?????section 12 – social support and spiritualitySelect who or what in your life is your support system FORMTEXT ? FORMCHECKBOX None FORMCHECKBOX Family FORMCHECKBOX Friends FORMCHECKBOX Religious group FORMCHECKBOX Support group FORMCHECKBOX Neighbors FORMCHECKBOX Social Media FORMCHECKBOX Other: FORMTEXT ?????Needs Referral FORMCHECKBOX Yes FORMCHECKBOX NoDo you want to disclose your HIV status to any one and you are having difficulty? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe FORMTEXT ?????Needs Referral FORMCHECKBOX Yes FORMCHECKBOX NoDo you feel unsafe in any current relationship or place of residence? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe FORMTEXT ?????Needs Referral FORMCHECKBOX Yes FORMCHECKBOX NoDescribe any cultural beliefs you think need to be shared. FORMTEXT ?????Comments FORMTEXT ?????section 13 – summariesSummary of Client Needs (per client) FORMTEXT ? FORMTEXT ?????Summary of Client Needs (per case manager) FORMTEXT ?????section 14 – signaturesCase Manager Name FORMTEXT ? FORMTEXT ?????Case Manager SignatureDate FORMTEXT ?????(Do not type beyond this point)The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.End of form ................
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