Patient ID
HIV Screening Labs Last Name:__________________ First Name:________________
I.D.#____________________________ DOB:_________________
Screening Date Result Screening Date Result
HIV Western Blot
AIDS Diagnosis
Toxo IgG
CMV IgG
Hep A Total
Hep B S Ag Hep C Ab
If (+) Hep B E Ag If (+) Hep C VL
Hep B surface Ab If (+) genotype
Hep B core Ab
Hep B VL G6PD
Vaccine Dates:
1 2
Hep A Vaccine TITER
1 2 3
Hep B Vaccine TITER
Twin Rx Booster recommendation:
Pneumovax (Repeat I in 6 yrs X 1)
Tetanus (Every 12 yrs or as needed)
Influenza (Annually)
MMR
CDC Staging A1 A2 A3 B1 B2 B3 C1 C2 C3
Date
Special Immunology:
Specimen Source: Date: Result:
Histoplasmosis Antigen
Specimen Source: Date: Result:
Cryptococcal Antigen
Past ARV Exposures
Intolerant of:
Filename: a572cee6-d26d-4e9c-bd08-8a526a68bc8b.doc
Created on 05/06/04
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