Wisconsin HIV Infection and AIDS Case Report, F-44338



DEPARTMENT OF HEALTH SERVICES (DHS)Division of Public HealthF-44338 (12/2019)STATE OF WISCONSINWis. Stat. § 252.05 requires that this information be reported.WISCONSIN HIV INFECTION AND AIDS CASE REPORT(Patients >13 Years of Age at Time of Diagnosis)PATIENT IDENTIFICATIONPatient’s Legal NameFirst NameMiddle Name Last Name FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Also Known As (e.g., alias, married, maiden)First NameMiddle Name Last Name FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Address Type FORMCHECKBOX Residential FORMCHECKBOX Correctional Facility FORMCHECKBOX Military Base FORMCHECKBOX Foster Home FORMCHECKBOX Homeless FORMCHECKBOX Postal FORMCHECKBOX Shelter FORMCHECKBOX Temporary FORMCHECKBOX OtherCurrent Street AddressIf current address is a facility (e.g., corrections, nursing home, shelter), provide name FORMTEXT ????? FORMTEXT ?????CityCountyState / CountryZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Telephone – PrimaryTelephone - SecondaryMedical Record NumberSocial Security Number (see page 4) FORMTEXT ??? - FORMTEXT ????? FORMTEXT ??? - FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PATIENT DEMOGRAPHICS (Record all dates as mm/dd/yyyy)Date of BirthAlias Date of BirthCountry of Birth FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX US FORMCHECKBOX Other / US Dependency - specify: FORMTEXT ?????Sex Assigned at BirthCurrent Gender Identity FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Male FORMCHECKBOX Transgender Male-to-Female (MTF) FORMCHECKBOX Unknown FORMCHECKBOX Unknown FORMCHECKBOX Female FORMCHECKBOX Transgender Female-to-Male (FTM FORMCHECKBOX Additional Gender Identity - specify: FORMTEXT ?????Ethnicity FORMCHECKBOX Hispanic/Latino FORMCHECKBOX Not Hispanic/Latino FORMCHECKBOX UnknownRace(check all that apply) FORMCHECKBOX American Indian/Alaska Native FORMCHECKBOX Asian1913890118110DHS State Number00DHS State Number FORMCHECKBOX Black/African America FORMCHECKBOX Native Hawaiian/Pacific Islander FORMCHECKBOX White FORMCHECKBOX UnknownRelationship Status FORMCHECKBOX Married FORMCHECKBOX Married and Separated FORMCHECKBOX Divorced FORMCHECKBOX Partnered / Significant Other FORMCHECKBOX Widowed FORMCHECKBOX Single and Never Married FORMCHECKBOX Unknown FORMCHECKBOX Other - specify: FORMTEXT ?????Vital Status: FORMCHECKBOX Alive FORMCHECKBOX DeadDate of DeathState of Residence at Time of Death FORMTEXT ????? FORMTEXT ?????RESIDENCE AT DIAGNOSIS (add additional addresses in Comments Section) FORMCHECKBOX Check if SAME AS CURRENT ADDRESS and go to the next sectionStreet Address at DiagnosisCityCountyState / CountryZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????FACILITY PROVIDING INFORMATION (Record all dates as mm/dd/yyyy)Facility Name FORMTEXT ?????Street Address FORMTEXT ?????CityCountyState/CountryZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????FacilityTypeInpatient FORMCHECKBOX Hospital FORMCHECKBOX Other (specify): FORMTEXT ?????Outpatient FORMCHECKBOX Private Physician’s Office FORMCHECKBOX Adult HIV Clinic FORMCHECKBOX Other - specify: FORMTEXT ?????Other Facility FORMCHECKBOX CTR FORMCHECKBOX STD Clinic FORMCHECKBOX Community Health Center FORMCHECKBOX Emergency Room FORMCHECKBOX Blood / Plasma Center FORMCHECKBOX Corrections FORMCHECKBOX Other - specify: FORMTEXT ?????Date Form CompletedPerson Completing FormTelephoneIf CTR Agency, provide client’s CTR test ID No.: FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? - FORMTEXT ????? FORMTEXT ?????Provider NameTelephoneSpecialty FORMTEXT ????? FORMTEXT ??? - FORMTEXT ????? FORMTEXT ?????FACILITY OF DIAGNOSIS FORMCHECKBOX Check if SAME as Facility Providing Information and go to the Next SectionFacility Name FORMTEXT ?????Street Address FORMTEXT ?????CityCityCityCity FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????FacilityTypeInpatient FORMCHECKBOX Hospital FORMCHECKBOX Other (specify): FORMTEXT ?????Outpatient FORMCHECKBOX Private Physician’s Office FORMCHECKBOX Adult HIV Clinic FORMCHECKBOX Other - specify: FORMTEXT ?????Other Facility FORMCHECKBOX CTR FORMCHECKBOX Emergency Room FORMCHECKBOX Blood / Plasma Center FORMCHECKBOX Corrections FORMCHECKBOX STD Clinic FORMCHECKBOX Community Health Center FORMCHECKBOX Other - specify: FORMTEXT ?????Provider NameTelephoneSpecialty FORMTEXT ????? FORMTEXT ??? - FORMTEXT ????? FORMTEXT ?????PATIENT HISTORY (Respond to ALL Questions) (record all dates as mm/dd/yyyy) After 1977 and before the earliest known diagnosis of HIV infection, this patient had:Sex with male FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownSex with female FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownInjected drugs not prescribed to patient FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownHETEROSEXUAL sexual relations with any of the following:Heterosexual contact with intravenous / injection drug user FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownHeterosexual contact with bisexual male FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownHeterosexual contact with person with hemophilia / coagulation disorder with documented HIV infection FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownHeterosexual contact with transfusion recipient with documented HIV infection FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownHeterosexual contact with transplant recipient with documented HIV infection FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownHeterosexual contact with person with documented HIV infection, risk not specified FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownOther – Answer only if statement describes mode of transmissionReceived clotting factor for hemophilia / coagulation disorder FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownSpecify clotting factor: FORMTEXT ?????Date received: FORMTEXT ?????Received transfusion of blood / blood components (other than clotting factor) (document reason in Comments Section) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownFirst date received: FORMTEXT ?????Last date received: FORMTEXT ?????Received transplant of tissue / organs or artificial inseminationDate received: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownWorked in a healthcare or clinical laboratory setting. If occupational exposure is being investigated or considered as primary mode of exposure, specify occupation and setting in Comments Section FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownPerinatally infected FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownOther documented risk (include detail in Comments Section) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownLABORATORY DATA (record additional tests in Comments Section) (record all dates as mm/dd/yyyy) HIV Antibody Test at Diagnosis (Non-differentiating) (Earliest Test)PosNegIndCollection DateHIV-1 EIA FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ?????HIV-1/2 EIA FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ?????HIV-1/2 Ag/AB FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ?????HIV-1 WB/IFA FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ?????HIV-2 EIA FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ?????HIV-2 WB FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ?????Other HIV AB TestSpecify: FORMTEXT ????? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ?????HIV Antibody Test at Diagnosis (Differentiating) (Earliest Test)HIV-1HIV-2BothNegCollection DateHIV-1/2 Multispot FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ?????HIV Detection/Viral Load Tests (Quantitative) (Earliest & Most Recent)Copies/mICollection DateHIV-1 RNA/DNA NAAT (earliest) FORMTEXT ????? FORMTEXT ?????HIV-1 RNA/DNA NAAT (most recent) FORMTEXT ????? FORMTEXT ?????HIV-2 RNA/DNA NAAT FORMTEXT ????? FORMTEXT ?????HIV Detection Tests (Qualitative) (Earliest Test)Collection DateHIV-1 RNA/DNA NAAT (Nucleic Acid Amplification Test) FORMCHECKBOX Detectable FORMCHECKBOX Undetectable FORMTEXT ?????HIV-2 RNA/DNA NAAT (Nucleic Acid Amplification Test) FORMCHECKBOX Detectable FORMCHECKBOX Undetectable FORMTEXT ?????Other Detection Test - Specify: FORMTEXT ????? FORMTEXT ?????Immunologic Tests (CD4)CD4 at or Closest to Current Diagnostic Status:Collection DateCount FORMTEXT ?????Percent FORMTEXT ?????% FORMTEXT ?????First CD4 <200 ?L or <14%: Count FORMTEXT ?????Percent FORMTEXT ?????% FORMTEXT ?????Most Recent CD4: Count FORMTEXT ?????Percent FORMTEXT ?????% FORMTEXT ?????Resistance TestsCollection DateGenotyping FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMTEXT ?????Phenotyping FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMTEXT ?????Past HIV TestingHas this patient ever had a negative HIV test? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf yes, specify test and date: FORMTEXT ?????If HIV laboratory tests were not documented, is the HIV diagnosis documented by a physician? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf yes, date of physician documentation: FORMTEXT ?????CLINICAL Definitive Diagnosis (record all dates as mm/dd/yyyy) Diagnosis DateCandidiasis, bronchi, trachea, or lungs FORMTEXT ?????Candidiasis, esophageal FORMTEXT ?????Carcinoma, invasive cervical FORMTEXT ?????Coccidioidomycosis, disseminated or extrapulmonary FORMTEXT ?????Cryptococcosis, extrapulmonary FORMTEXT ?????Cryptosporidiosis, chronic intestinal (>1 mo. duration) FORMTEXT ?????Cytomegalovirus disease (other than in liver, spleen, or nodes) FORMTEXT ?????Cytomegalovirus retinitis (with loss of vision) FORMTEXT ?????HIV encephalopathy FORMTEXT ?????Herpes simplex: chronic ulcers (>1 mo. duration), bronchitis, pneumonitis, or esophagitis FORMTEXT ?????Histoplasmosis, disseminated or extrapulmonary FORMTEXT ?????Isosporiasis, chronic intestinal (>1 mo. duration) FORMTEXT ?????Kaposi’s sarcoma FORMTEXT ?????Lymphoma, Burkitt’s (or equivalent) FORMTEXT ?????Lymphoma, immunoblastic (or equivalent) FORMTEXT ?????Lymphoma, primary in brain FORMTEXT ?????Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary FORMTEXT ?????M. tuberculosis, pulmonary FORMTEXT ?????M. tuberculosis, disseminated or extrapulmonary FORMTEXT ?????Mycobacterium, of other / unidentified species, disseminated or extrapulmonary FORMTEXT ?????Pneumocystis pneumonia FORMTEXT ?????Pneumonia, recurrent, in 12 mo. period FORMTEXT ?????Progressive multifocal leukoencephalopathy FORMTEXT ?????Salmonella septicemia, recurrent FORMTEXT ?????Toxoplasmosis of brain, onset at >1 mo. of age FORMTEXT ?????Wasting syndrome due to HIV FORMTEXT ?????ANTIRETROVIRAL (ARV) USE HISTORY / SERVICE REFERRALS (record all dates as mm/dd/yyyy)Has patient ever been prescribed antiretrovirals (ARVs)? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownDate first began FORMTEXT ?????Date of last use FORMTEXT ?????Has this patient been informed of his/her HIV infection? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownTest ResultDate of TestHas patient been tested for syphilis? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Positive FORMCHECKBOX Negative FORMCHECKBOX Unknown FORMTEXT ?????Has patient been tested for hepatitis C? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Positive FORMCHECKBOX Negative FORMCHECKBOX Unknown FORMTEXT ?????Has patient been tested for TB? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Positive FORMCHECKBOX Negative FORMCHECKBOX Unknown FORMTEXT ?????For Female Patients (record all dates as mm/dd/yyyy)This patient is receiving or has been referred for gynecological or obstetrical services: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIs this patient currently pregnant? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownHas this patient delivered live-born infants? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf patient is currently pregnant,estimated date of delivery: FORMTEXT ?????If currently pregnant, has patient been referred to the Wisconsin HIV Primary Care Support Network? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown Date of referral: FORMTEXT ?????DHS USE ONLYDate Received at Health Department FORMTEXT ?????Partner Services Referral Completed FORMTEXT ?????Name - Agency / Field Worker FORMTEXT ?????WI HIV County FORMTEXT ?????RVCT Number FORMTEXT ?????Other State Numbers FORMTEXT ?????COMMENTS FORMTEXT ?????Complete and return in an envelope marked “CONFIDENTIAL” to:Scott StokesDivision of Public HealthPO Box 2659MADISON WI 53701-2659Fax to 608-266-1288 or call 608-267-5287 with information or questions (ask to be connected with a Surveillance Specialist).Confirmed and suspect cases of HIV infection and AIDS are required to be reported to the Division of Public Health per Wis. Stat. § 252.05. Information provided is confidential as required per Wis. Stat. § 252.15.Disclosure of Social Security Number is voluntary. The Social Security Number and other information on this form are used for surveillance, control and prevention of HIV infections. The information is collected with a guarantee that it will be held in confidence, will be used only for the purposes stated and will not otherwise be disclosed or released without the consent of the individual. ................
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