Minnesota Adult HIV/AIDS Confidential Case Report (for patients > 13 years of age at time of diagnosis)
Return completed form to Minnesota Department of Health
Attn: HIV Surveillance Unit, 625 Robert Street N., P.O. Box 64975, St. Paul, MN 55164-0975
Telephone: 651-201-5414 TTY: 651-201-5797
Date form completed (enter all
dates in mm/dd/yyyy format)
/
/
/
/
I. Health Department Use Only
revised 5/22/2015
Did this report initiate a
new case investigation?
Soundex Code
A
Surveillance Method
F
P
R
Yes
U
No
Other State/City/County Number
Reporting Health Department
State/City/County
Field Visit
Report Medium
Mailed
/
Date Received at MDH
State Patient No.
Faxed
/
Phone
Electronic Transfer
Document Source
CD/Disk
or Source Code
II. Patient Name (last, first, middle initial), Locating Information and Identification
Patient's Name
Alias
Home
Phone
-
-
-
Cell
Address
-
City
-
SSN
-
-
Work
State
-
County
Zip
Other locating
Med Rec #
III. Demographic Information
Diagnostic
Status
at Report
Country
of Birth
HIV infection
Date of Birth
(not AIDS)
(mm/dd/yyyy)
AIDS
/
/
Language Spoken
United States
Alias Date of Birth
(mm/dd/yyyy)
/
Yes
No
Ethnicity
Current Gender Identity
Date of Death
(mm/dd/yyyy)
Race
Male
Male
Hispanic/Latino
Am. Indian/Alaska Native
Female
Female
Not Hispanic/Latino
Asian
Unknown
Transgender Male to Female (MTF)
Unknown
Black/African American
Transgender Female to Male (FTM)
Expanded Ethnicity
Native Hawaiian/Pac Isl
/
Is this person a licensed
healthcare worker?
No
Yes
Unknown
White
Additional Gender Identity (specify)
Unknown
Single
Married
Divorced
Separated
Widowed
If yes, enter occupation and location
Unknown
Other (specify)
Partner/Spouse Name
Phone
Emergency Contact
Residence at HIV Diagnosis
Residence at AIDS Diagnosis
Address
-
-
Same as current address
Address
Unknown
/
Expanded Race
Marital Status
Alive
Dead
Interpreter
Needed?
Other: specify
Sex at Birth
Vital
Status
/
City
County
State
Zip
City
County
State
Zip
Same as current address
IV. Facility and Provider of Diagnosis / Facility of Care
Facility of Diagnosis
City/State/Zip Code
Inpatient
Outpatient
Screening, Diagnostic, Referral Agency
Other Facility
Hospital
Private Physician's Office
CTS
Emergency Room
Corrections
Other (specify)
Adult HIV Clinic
STD Clinic
Laboratory
Unknown
Other (specify)
Other (specify)
Other (specify)
Provider
Name
Provider
Phone
-
-
Person Completing
Form:
Specialty
-
Phone
-
V. Patient History
(Respond to all questions. Record all dates as mm/dd/yyyy)
Pediatric risk (please enter in Comments below)
After 1977 and before the earliest known diagnosis of HIV infection, this patient had:
Sex with male
Yes
No
Unknown
Sex with female
Yes
No
Unknown
Injected non-prescription drugs
Yes
No
Unknown
Received clotting factor for hemophilia/coagulation disorder
Yes
No
Unknown
HETEROSEXUAL contact with intravenous/injection drug user
Yes
No
Unknown
HETEROSEXUAL contact with bisexual male
Yes
No
Unknown
HETEROSEXUAL contact with person with hemophilia / coagulation disorder with documented HIV infection
Yes
No
Unknown
HETEROSEXUAL contact with transfusion recipient with documented HIV infection
Yes
No
Unknown
HETEROSEXUAL contact with transplant recipient with documented HIV infection
Yes
No
Unknown
HETEROSEXUAL contact with person with documented HIV infection, risk not specified
Yes
No
Unknown
Received transfusion of blood/blood components (other than clotting factor) (document reason in Comments section)
Yes
No
Unknown
Received transplant of tissue/organs or artificial insemination
Yes
No
Unknown
Worked in a healthcare or clinical laboratory setting
Yes
No
Unknown
Yes
No
Unknown
Date received
(mm/dd/yyyy)
Specify clotting
factor:
/
/
HETEROSEXUAL relations with any of the following:
First date
received
/
/
Last date
received
/
/
If occupational exposure is being investigated or considered as primary mode of exposure, specify occupation and setting:
Other documented risk (please include detail in Comments section)
Comments:
VI. Laboratory Data (record additional tests in Comments section) (record all dates as mm/dd/yyyy)
HIV Antibody Tests (Non-type-differentiating)
TEST 1:
HIV-1 IA
RESULT:
Positive/Reactive
HIV-1/2 IA
HIV-1/2 Ag/Ab
HIV-1 WB
Negative/Nonreactive
HIV-1 IFA
Indeterminate
HIV-1 IA
RESULT:
Positive/Reactive
HIV-1/2 IA
HIV-1/2 Ag/Ab
HIV-1 WB
Negative/Nonreactive
HIV-2 WB
HIV-1 IFA
HIV-2 IA
HIV-2 WB
RAPID TEST (check if rapid)
Indeterminate
Manufacturer:
TEST 3:
HIV-1 IA
RESULT:
Positive/Reactive
HIV-1/2 IA
HIV-1/2 Ag/Ab
HIV-1 WB
Negative/Nonreactive
Other: Specify:
RAPID TEST (check if rapid) Collection
Date:
Manufacturer:
TEST 2:
HIV-2 IA
HIV-1 IFA
Indeterminate
HIV-2 IA
/
Other: Specify:
Collection
Date:
HIV-2 WB
/
/
HIV Antibody Tests (Type-differentiating) [HIV-1 vs. HIV-2]
TEST:
HIV-1/2 Type-differentiating (e.g., Multispot)
RESULT:
HIV-1
HIV-2
Both (undifferentiated)
Neither (negative)
Indeterminate
Collection
Date:
HIV Detection Tests (Qualitative)
TEST 1:
HIV-1 RNA/DNA NAAT (Qual)
RESULT:
Positive/Reactive
TEST 2:
HIV-1 RNA/DNA NAAT (Qual)
RESULT:
Positive/Reactive
HIV-1 P24 Antigen
Negative/Nonreactive
HIV-1 P24 Antigen
Negative/Nonreactive
HIV-1 Culture
Indeterminate
HIV-2 RNA/DNA NAAT (Qual)
Indeterminate
HIV-2 RNA/DNA NAAT (Qual)
Collection Date:
HIV Detection Tests (Quantitative viral load) Note: Include earliest test at or after diagnosis
TEST 1:
HIV-1 RNA/DNA NAAT (Quantitative viral load)
RESULT:
Detectable
TEST 2:
HIV-1 RNA/DNA NAAT (Quantitative viral load)
RESULT:
Detectable
Undetectable
Undetectable
HIV-2 RNA/DNA NAAT (Quantitative viral load)
Copies/mL:
Collection Date:
Log:
HIV-2 RNA/DNA NAAT (Quantitative viral load)
Copies/mL:
Log:
Collection Date:
Immunologic Tests (CD4 count and percentage)
CD4 at or closest to current diagnostic status: CD4 count:
First CD4 result <200 cells/μL or <14%: CD4 count:
Other CD4 result: CD4 count:
cells/μL CD4 percentage:
%
Collection Date:
cells/μL CD4 percentage:
%
Collection Date:
cells/μL CD4 percentage:
%
Collection Date:
Documentation of Tests
Did documented laboratory test results meet approved HIV diagnostic algorithm criteria?
Yes
No
Unknown
If YES, provide date (specimen collection date if known) of earliest positive test for this algorithm:
Complete the above only if none of the following was positive: HIV-1 Western blot, IFA, culture, p24 Ag test, viral load, or qualitative NAAT [RNA or DNA]:
If HIV laboratory tests were not documented, is HIV diagnosis documented by a physician?
Yes
No
If YES, provide date of diagnosis:
Date of last documented negative HIV test (before HIV diagnosis date):
HIV-2 Culture
Collection Date:
HIV-1 Culture
Specify type of test:
Unknown
/
Other: Specify:
RAPID TEST (check if rapid) Collection
Date:
Manufacturer:
/
HIV-2 Culture
/
VII. Clinical (record all dates as mm/dd/yyyy)
Diagnosis
OIs
DX Date
Diagnosis
Candidiasis, bronchi, trachea,
or lungs
OIs
DX Date
Diagnosis
Herpes simplex: chronic ulcers
(>1 mo. duration), bronchitis,
pneumonitis, or esophagitis
OIs
M. tuberculosis, pulmonary†
M. tuberculosis, disseminated or
extrapulmonary†
Candidiasis, esophageal
Carcinoma, invasive cervical
Histoplasmosis, disseminated or
extrapulmonary
Coccidioidomycosis,disseminated
or extrapulmonary
Isosporiasis, chronic intestinal
(>1mo. duration)
Mycobacterium, of other/
unidentified species,
disseminated or extrapulmonary
Kaposi’s sarcoma
Pneumocystis pneumonia
Lymphoma, Burkitt’s (or equivalent)
Pneumonia, recurrent, in 12 mo.
period
Cryptococcosis, extrapulmonary
Cryptosporidiosis, chronic
intestinal (>1 mo. duration)
Cytomegalovirus disease (other
than in liver, spleen, or nodes)
Progressive multifocal
leukoencephalopathy
Lymphoma, immunoblastic (or
equivalent)
Cytomegalovirus retinitis (with
loss of vision)
Salmonella septicemia, recurrent
Lymphoma, primary in brain
HIV encephalopathy
Toxoplasmosis of brain, onset at >1
mo.of age
Mycobacterium avium complex
or M. kansasii, disseminated or
extrapulmonary
If TB selected above, indicate
RVCT Case Number:
†
Wasting syndrome due to HIV
VIII. Treatment/Services Referrals
Ever had a negative HIV test?
Yes
Ever had a previous positive HIV test?
No
Yes
Refused
No
Don't Know/Unknown
Refused
Date of last negative HIV test (If date is from a lab test with
test type, enter in Lab Data section)
Don't Know/Unknown
Date of first positive HIV test
Has this patient been informed of his/her HIV infection?
Yes
No
Unknown
Is this patient receiving or has been referred for HIV related medical services?
Yes
No
Unknown
Has this patient been referred to an Infectious Disease (ID) Clinic?
Yes
No
Unknown
Provider Phone
If yes, Provider Name
Last Appointment Date/Time:
Ever taken any antiretrovirals (ARVs)?
Next Appointment Date/Time:
Yes
No
If yes, ARV Medication
Refused
Don't Know/Unknown
Dates ARVs taken Date first began:
Date of last use:
IX. For Female Patients
This patient is receiving or has been referred for gynecological or obstetrical services:
Is this patient currently pregnant?
Has this patient delivered live-born infants?
Yes
Due Date:
Yes
No
Yes
No
Unknown
No
Unknown
Unknown
Children of Patient (record information below; if more than 2 children please use the Comments section)
Child’s Name
Child's Date of Birth
Hospital of Birth (if child was born at home, enter “home birth” for hospital name)
Hospital Name:
Address
Country
City
State
Zip Code
Children of Patient (record information below; if more than 2 children please use the Comments section)
Child’s Name
Child's Date of Birth
Hospital of Birth (if child was born at home, enter “home birth” for hospital name)
Hospital Name:
Address
Country
City
State
Zip Code
DX Date