Pre-Exposure Prophylaxis Intake Information

(add V6544 to Disease Registry; fee item 00110/15310/16310, etc/Dx code V654)

Date:
Patient:
Gender Identification:
Patient Demographics:
MRP

Relevant Medical History

Check all that apply: Chronic Active Hepatitis B Chronic Active Hepatitis C Chronic Kidney Disease Diabetes Hypertension Depression/Anxiety Osteoporosis Other: Comments:

Relevant Labs

Renal Status:   eGFR:       Date:     Cr:     Date: HIV Status:   HIV Ab/Ag EIA:       Date:     (N.B. window period 14-21 days) HAV Status:   HAV total (IgG+IgM):       Date:                        HAV IgG Only:       Date: HBV Status:   HBsAg:       Date:                        HBsAb:       Date:                        HBsAb:       Date: HCV Status:   HCV Ab:     Date: Syphilis Status:   T Pall. EIA:       Date:   RPR titre:       Date: Other Labs: Comments:

Current Medications
Allergies
Adverse Reactions

Prior STI’s Ever

Gonorrhea     Yes   No   Unknown     If yes, Rectal   Urethral   Pharygneal

Chlamydia     Yes   No   Unknown     If yes, Rectal   Urethral   Pharygneal

Syphilis          Yes   No   Unknown

Comments:

Family History

BP CVA MI Lipid DM Thyroid Cancer Glaucoma GI GU MSK Resp Allergy EtOH Psych

Lifestyle
Smoking	Never Quit Occas Active cig/day      Start:   Quit:
Caffeine	/day
Alcohol	/wk         Problematic alcohol use: Yes   No   Unknown
Drugs	IVDU:                                   Yes   No   Unknown       Crystal                                 Yes   No   Unknown         Methamphetamine: Cocaine:                              Yes   No   Unknown   Ecstacy:                               Yes   No   Unknown   GHB:                                    Yes   No   Unknown   Ketamine:                             Yes   No   Unknown   Heroin:                                 Yes   No   Unknown   Other substance:                 Yes   No   Unknown
Diet
Fitness

Social History
Relationship Status	Single Married Common Law Separated Divorced Widowed
Partner's Name
Sexual Partners	M F Both None       HIRI score     HIRI date
Sexual Concern
Assault/Abuse
Education
Occupation

Immunization History
Primary Series
Last Tetanus Toxoid
Rubella
Hep A	Has had HAV vaccine: Yes No Unsure     HAV titre:     Date:
Hep B	Has had HBV vaccine: Yes No Unsure     HBV titre:     Date:
HPV	Has had HPV vaccine: Yes No Unsure     Date:
Flu Vaccine
Pneumo 23
Varicella Vaccine	Has had Chicken Pox: Yes No Unsure

Immunization Record
Date Immunization Lot Number