Patient Information
Patient’s Name (Last, First): ______If patient is minor, Name of Guardian: ______
Preferred Name (nickname): ______Maiden Name: ______
Street Address: ______City: ______Zip code: ______
Telephone # Home: ______Work or Mobile: ______Email: ______
Provider Questions
Testing and Vaccination - encourage providers to FAX information to 215-238-6947 (attention: Danica Kuncio)
Physician: ______Physician Phone: ______Health Care Institution: ______Institution Address: ______
Liver Enzyme Levels at Time of Diagnosis: Result Result Date Lab Name
ALT [SGPT] (Ref: 0-55) ______/_____/______
AST [SGOT] (Ref: 0-40) ______/_____/______
Bilirubin ______/_____/______
Test Pos Neg Unk Collection Date Result Date LabA / IgM anti-104 □ □ □ ___/___/______/___/______
Total anti-104 □ □ □ ___/___/______/___/______
B / IgM HBc □ □ □ ___/___/______/___/______
Total anti-HBc □ □ □ ___/___/______/___/______
Anti-HBs □ □ □ ___/___/______/___/______
HBsAg □ □ □ ___/___/______/___/______
105 DNA □ □ □ ___/___/______/___/______
105 Other:______□ □ □ ___/___/______/___/______
C / Anti-106 Signal-to-Cutoff ratio:
______□ □ □ ___/___/______/___/______
RIBA □ □ □ ___/___/______/___/______
106 RNA (PCR) □ □ □ ___/___/______/___/______
106 Genotype: ______□ □ □ ___/___/______/___/______
106 Other: ______□ □ □ ___/___/______/___/______
D / anti-HDV □ □ □ ___/___/______/___/______
E / Anti-HEV □ □ □ ___/___/______/___/______
Vaccine/Ig Date Dose Received Approx Date? Provider In KIDS? In HCP Record?
Yes No Yes No Yes No
104 Vaccine ____/_____/______□ □ ______□ □ □ □
____/_____/______□ □ ______□ □ □ □
Yes No Yes No Yes No
105 Vaccine ____/_____/______□ □ ______□ □ □ □
____/_____/______□ □ ______□ □ □ □
____/_____/______□ □ ______□ □ □ □
REASON FOR TESTING (check all that apply):
□ Symptoms of acute disease □ Evaluation of elevated liver enzymes □ Screening of asymptomatic patient (reported risk factors) □ Blood/organ donor screening □ Screening of asymptomatic patient with no risk factors (patient requested) □ Follow-up testing for previous marker □ Age □ Prenatal screening if yes, delivery date: ___/___/____ □ Routine screen □ Unknown □ Other, specify: ______
How many times have you seen this patient in the last year? □ 1 □ 2-3 □ >3
PHYSICIAN DIAGNOSIS: □ Acute □ Chronic □ Unknown
Demographics
RACE: □ Black □ White □ Asian - Specify Type: ______□ African □ Pacific Islander □ Pacific Islander □ Native American □ Other ______
HISPANIC □ Yes □ No □ Unk SEX: □ Female □ Male □ Transgender □ FTM □ MTF DATE OF BIRTH: ____/_____/_____
PLACE OF BIRTH: □ USA □Other: ______AGE: ______mo/yr PRIMARY LANGUAGE: ______MOTHER’S BIRTH COUNTRY: ______FATHER’S BIRTH COUNTRY: ______
Clinical and Risk Factors
CLINICAL: YES NO UNK
Has patient been informed of test results? □ □ □
Is patient symptomatic? □ □ □
If yes, onset date: _____/_____/______
Was the patient
Jaundiced? □ □ □
Hospitalized for 106? □ □ □
Did the patient die from 106? □ □ □
If yes, date of death? _____/_____/______
Has the patient been referred to a specialist? □ □ □
If yes, name: ______
Institution: ______
Does the patient have health insurance? □ □ □
If yes, specify: Public □ type: ______Private □
RISK FACTOR:
Has patient EVER: YES NO UNK
Used injection drugs? □ □ □
Been incarcerated for over 24 hrs? □ □ □
Had contact with a person who had 106? □ □ □
If yes, type of contact:
Household □ Needle_use □ Sexual □
Maternal_Infant □ Other □ ______
Been employed in a medical/dental field? □ □ □
Been on long-term hemodialysis? □ □ □
Had a needlestick exposure? □ □ □
Unmet Needs:
Would your office like additional information about 106? Yes □ No □ Unk □ If yes, by: mail □ email □______
Provider Notes:
Name of person completing form: ______Affiliation of person completing form: ______
Title of person completing form: ______
Patient Questions
RACE: □ Black □ White □ Asian - Specify Type: ______□ Pacific Islander □ Native American □ Other ______
HISPANIC □ Yes □ No □ Unk SEX: □ Female □ Male □ Transgender □ FTM □ MTF DATE OF BIRTH: ____/_____/_____
PLACE OF BIRTH: □ USA □ Other: ______AGE: ______mo/yr PRIMARY LANGUAGE: ______MOTHER’S BIRTH COUNTRY: ______FATHER’S BIRTH COUNTRY: ______
Risk Factors and Exposures
Did you know that you were being tested for 106? □ Yes □ No □ Unk
If yes, did you understand the information given to you? □ Yes □ No □ Unk
What year were you first diagnosed with 106? ______In what city/state were you diagnosed? ______
Do you have symptoms of 106? □ Yes □ No □ Unk Do you have jaundice? □ Yes □ No □ Unk
Type of health insurance? Public (Medicaid or other) □ Private □ Uninsured □ Unknown □
Did you ever: YES NO UNK
Receive a blood transfusion prior to 1992? □ □ □
Receive an organ transplant prior to 1992? □ □ □
Receive clotting factor conc. produced prior to 1987? □ □ □
Live outside the US for an extended period (>6 months)? □ □ □
If yes, where? ______
If yes, in military service? □ □ □
Use street drugs? □ □ □
If yes, how: Inject □ Smoke □ Other, specify ______
Have a job requiring direct contact with human blood? □ □ □
Receive surgery/other invasive procedure? □ □ □
If yes, approx.. date: ______
Receive a tattoo? □ □ □
If yes, location: Commercial parlor/shop □ Tattoo party □
Correctional Facility □ Friend or relative □
Other, specify ______□
If yes, approx. date of most recent tattoo: ______
Contacts
How many people are living in your household? Children (<18 yo) ____ Adults (≥ 18 yo) _____
Unmet Needs
YES NO UNK
Do you receive care for your 106 infection? □ □ □
If yes, specify by: PCP □ ______Specialist □ ______
Have you ever taken medication for 106? □ □ □
If yes, medication regimen? ______
If yes, prescribed by? ______
If yes, currently? ______
For past or current drug users only:
Have you been in a drug treatment program? □ □ □ Do you know the location of community NEPs? □ □ □
Would you like additional information regarding 106? YES NO UNK □ □ □ □
If yes, method: mail □ email □ ______
Patient Notes
Administrative
Investigator:Lab Investigation
Date Lab call #1: ___/___/______AM/PM / Date Lab call #2: ___/___/______AM/PM
Outcome call #1: Complete – lab results given by phone □
Complete – labs FAXed to PDPH □
Busy □ No Answer □ Wrong # □ / Outcome call #2: Complete – lab results given by phone □
Complete – labs FAXed to PDPH □
Busy □ No Answer □ Wrong # □
Provider Investigation
Date provider letter sent: ___/___/_____
Date provider call #1: ___/___/______AM/PM / Date provider call #2: ___/___/______AM/PM
Outcome call #1: Complete □ Busy □ Wrong # □
Disconnected □ No Answer □
Refused □ Left message □ / Outcome call #2: Complete □ Busy □ Wrong # □
Disconnected □ No Answer □
Refused □ Left message □
Notes call #1: / Notes call #2:
Date provider call #3: ___/___/______AM/PM / Date provider warning call: ___/___/______AM/PM
(to alert providers that a field visit is imminent)
Outcome call #3: Complete □ Busy □ Wrong # □
Disconnected □ No Answer □
Refused □ Left message □ / Outcome warning call: Complete □ Busy □ Wrong # □
Disconnected □ No Answer □
Refused □ Left message □
Notes call #3: / Notes warning call:
Date field visit: ___/___/______AM/PM / Provider Investigation Complete? Yes □ No □
Notes field visit:
Patient Investigation
Date patient letter sent: ___/___/_____
Date patient call #1: ___/___/______AM/PM / Date patient call #2: ___/___/______AM/PM
Outcome call #1: Complete □ Busy □ Wrong # □
Disconnected □ No Answer □
Refused □ Left message □ / Outcome call #2: Complete □ Busy □ Wrong # □
Disconnected □ No Answer □
Refused □ Left message □
Notes call #1: / Notes call #2:
Date patient call #3: ___/___/______AM/PM / Date patient warning call: ___/___/______AM/PM
(to alert patients that a field visit is imminent)
Outcome call #3: Complete □ Busy □ Wrong # □
Disconnected □ No Answer □
Refused □ Left message □ / Outcome warning call: Complete □ Busy □ Wrong # □
Disconnected □ No Answer □
Refused □ Left message □
Notes call #3: / Notes warning call:
Date field visit: ___/___/______AM/PM / Patient Investigation Complete? Yes □ No □
Notes field visit:
Investigator Close Date: ___/___/______AM/PM
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