Name:
URN#:
DOB:
Sex:
RYAN WHITE PROGRAM PART A
Charlotte Transitional Grant Area (TGA)
Case Management Assessment Tool
General:
Date of Assessment: _________
Agency ID #:
Client’s full name:
Location of Assessment:
Was information obtained during the assessment provided by person(s) in addition to the client? Yes
No
If yes who?
Relationship:
Phone:
********************************************************************************************
Please refer to original intake and assessment for any demographic information.
************************************************************************************
Education:
Educational level: Grade School
High School/GED
Associates Degree
Undergraduate Degree
Graduate/Post Grad. Degree
Reading Ability/Literacy: High
Moderate
Limited
Race/Ethnicity:
Race:
African American/Black
Asian/Pacific Islander
Black/Non-Hispanic
Other:
Latino/Hispanic
Native American
White/Non-Hispanic
Housing:
Apartment/Condo
House
Mobile Home
Rent
Own
Other
Also check one of the following: Permanent (stable)
Current Housing Programs: HOPWA
None
Unknown
Other:
Group Home
Transitional
Homeless
Non-Permanent
Section 8
Housing Authority
Does the client have any physical impairments/limitations that affect his/her safety in the home?
Yes
No
If yes, please describe
Are there any structural or functional inadequacies in the client’s home?
Yes
No
If yes, please describe
Adequate
Overcrowded
Criminal Activity
No Indoor Plumbing
Substandard
Unaffordable
Threat of Physical Violence
Other:
Unknown
Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Make any other comments about the client’s home environment you have observed that may have an effect on his/her
ability to function independently
Are there other persons (Adults/Non-dependent Children) in the household? Yes
No
If yes, please note below:
Name
Relationship
Age
May We Contact?
Aware of HIV Status?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Does the client have dependent children? Yes
No
If yes, complete the following:
Name
DOB
HIV
Name of
Contact Person
Phone Number
Aware of HIV
Status
School/Daycare
Status?
Yes
No
Yes
No
Yes
No
Transportation:
Does client have access to transportation? Yes
No
If no, please describe client’s ability to access transportation:
Insurance:
Medicare: Yes
No
MEDICAID: Yes
Expiration Date:
Medicare #:
Effective Date:
No
MEDICAID #:
Date applied if pending:
A
Effective Date:
VA Benefits: Yes
No
Date applied if pending:
Effective Date:
Expiration Date:
ADAP: Yes
No
Date applied if pending:
Effective Date:
Expiration Date:
Name of Ins. Co.:
Subscriber #:
Date applied if pending:
Effective Date:
Employer:
COBRA coverage: Yes
Group #
Expiration Date:
Private Insurance: Yes
Group #
Expiration Date:
Employer:
No
No
Name of Ins. Co.:
Subscriber #:
Date applied if pending:
Occupation:
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B
Effective Date:
Last updated 4/27/10
D
Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Other coverage: Yes
Group #
Expiration Date:
Employer:
No
Name of Ins. Co.:
Subscriber #:
Date applied if pending:
Occupation:
Effective Date:
Financial Resources:
Household Income per month (includes income of client and other household members)
Income
Client Income Source
Employment
SSD
SSI
Food Stamps
TANF
Unemployment
VA Benefits
Other
Total
Expenses
Status
(please check one)
(yes no pending
(yes no pending
(yes no pending
(yes no pending
(yes no pending
(yes no pending
(yes no pending
(yes no pending
Amount
)
)
)
)
)
)
)
)
Amount
Rent/Mortgage
Car Payment
Transportation
Credit Card/Loans
Health Care
Insurance
Utilities
Phone
Food
Child Support
Alimony
Entertainment
Other
Total Monthly Expenses
Assets
Source
Life Insurance
Checking
Source
Amount
Savings
Property
Burial Insurance
Total
Total Monthly Income
- Total Monthly Expenses
Total Monthly Cash Flow
Confirmed Zero Income
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Yes
No
Last updated 4/27/10
Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Legal Issues:
Legal Documents Status: Please check as appropriate.
DOCUMENT
NEEDED
Will
Durable Power of Attorney
Living Will
Health Care Power of Attorney
Guardianship
Burial Plans
Other:
NOT INTERESTED
COMPLETED
Legal Problems Status: Please indicate information as appropriate.
CHARGES
APPROXIMATE DATE
LOCATION
(state, county)
DISPOSITION
Health:
Primary Care Physician:
Phone Number:
Infectious Disease Physician:
Phone Number:
Medical Facility most often used:
Contact:
Are there any known allergies (drugs, food, and animals, other)? Yes
Please list known allergies
No
Does the client have any diagnosed health problems (heart disease, TB, hepatitis, other)? Yes
Diagnosed Health Problems
Treatments
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Phone Number:
No
Date of Treatment
Last updated 4/27/10
Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Has the client ever been hospitalized?
Yes
If yes, please complete the following:
Date
Hospital
No
Length of Stay
Reason
Dental:
Does the client receive dental care? Yes
If yes name of dentist:
No
Phone number:
Does the client have mouth/dental problems that affect what or how much she/he can eat: Yes
No
If yes, please describe:
Is there a history of opportunistic infections? Please check yes or no)
OI
PCP
CMV Retinitis
Histoplasmosis
Cryptosporidium
Kaposis Sarcoma
Shingles
Toxoplasmosis
Coccidiomycosis
Crytococcal Meningitis
TB
Invasive Cervical Cancer
History
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Date
Other?
On PCP prophylaxis? Yes
No
Is there a history of other HIV related conditions? (Please check yes or no)
Fevers
Yes
No
Virginities
Night Sweats
Yes
No
PID
Chills
Yes
No
Thrush
Fatigue
Yes
No
Dysphagia
Malaise
Yes
No
Cold Sores
Weight Loss >10 lbs
Yes
No
Seizures
Loss of Appetite
Yes
No
Change in Vision
Diarrhea > 1wk
Yes
No
Periodontal Disease
Herpes
Yes
No
Short Term Memory Loss
Syphilis
Yes
No
Hepatitis
Page 5
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Last updated 4/27/10
Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
If yes: please comment on these illnesses or others:
Describe any other health concerns not identified above:
Does the client have any visual or hearing impairment?
What affect does the client feel his/her health status has on their ability to work?
What does the client identify as the greatest barriers to keeping medical appointments?
How frequently does the client miss or reschedule medical appointments?
**Current Medications: Please complete the Medical Review and Medications List as part of this
assessment/reassessment. Include HIV, Non-HIV, Psychotropic Medications, OTC Medications, Herbal
Remedies, etc, on the list. Include the most current CD 4 and Viral Load data available.
If taking medications how does the client feel after taking medications?
Name of pharmacy/service and contact number (if applicable):
What barriers does the client identify to taking medications as prescribed?
Identify any past and/or current self-treatments, alternative therapies, etc., and its importance to the client.
How does the client rate his/her overall health?
excellent
good
fair
poor
How many meals does the client eat each day?
0-1
2-3
4-5
6+
Does the client seem to have a well balanced diet (fruits, vegetables, grains, proteins and dairy)? Yes
No
Please make any other comments you feel necessary to describe nutritional needs:
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Last updated 4/27/10
Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
ADL’s/IADLs:
Describe client’s ability to function independently in the following areas.
Activity of Daily Living
Does Client Need
Type of Assistance
Assistance?
Needed
Ability to Ambulate
Yes
No
Ability to Transfer Self
Yes
No
Ability to Feed Self
Yes
No
Ability to Toilet
Yes
No
Ability to Bathe Self
Yes
No
Ability to Groom Self
Yes
No
Ability to Dress Self
Yes
No
Source of Assistance
Others?
Instrumental Activity of
Daily Living
Housecleaning
Does the Client Need
Assistance?
Yes
No
Laundry
Yes
No
Shopping
Yes
No
Medication Management
Yes
No
Money Management
Yes
No
Ability to use phone
Yes
No
Type of assistance
needed:
Source of assistance
received:
Others?
Recreation/Leisure:
What does the Client do for fun or stress relief?
Spirituality:
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Last updated 4/27/10
Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
How does Religion play a role in the Client’s life?
What gives the client’s life purpose or meaning? What gives the client hope?
Are there any rituals or beliefs that may impact your healthcare? Yes
No
If yes, please describe:
Substance Use:
Identify current or past use of any substances including alcohol, tobacco, prescription and OTC medications:
Frequency of
Average
Date of last
Does client identify
Substance
use over past 30
quantity of
use
use as a problem
days
use/day
Yes
Yes
Yes
Yes
Is the client willing to receive a referral to a substance use counselor? Yes
If no explain:
No
No
No
No
No
Risk:
Substance Abuse
Mental Illness
Bisexual Contact
Heterosexual Contact
Blood Product Recipient
Sexual partner of prisoner
Exposed in healthcare
Setting
Homosexual contact
Perinatal Transmission
Other/undetermined
Risk Reduction Counseling
Received
Yes
No
What is the client’s understanding and use of safer practices to avoid transmission of or re-infection with HIV?
What are the barriers to the client using safer practices?
Does the client believe s/he may currently have a STD?
Does the client need referral for STD testing and/or treatment? Yes
Does the client need safer sex and/or drug use education? Yes
Has client notified past/current partners of HIV status? Yes
Page 8
No
No
No
Last updated 4/27/10
Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
If no, describe what steps you took to assist client in this process (such as referral to DIS/Health Department).
Please make any other comments you feel may impact client’s efforts at risk reduction:
Describe your sleep pattern. (Do you wake up in the middle of the night? Do you wake up early? Do you have
trouble falling asleep?). Is this a “regular pattern” for you? Do you feel rested upon waking?
Mental Health:
Is client’s grooming/appearance appropriate? Yes
Motor coordination:
Thought content:
Memory:
Judgment:
good
Clear
Impaired
Impaired
fair
Impaired
Unimpaired
No
Is client oriented x3? Yes
No
poor
If impaired describe
If impaired describe
Unimpaired Insight:
Appears to be under the influence of a substance? Yes
Do you have any psychiatric history/diagnosis? Yes
Impaired
Somewhat Impaired
Intact.
No
No
If yes, explain
Have you had a significant period (that was not a direct result of drug/alcohol use) in which you have?
Past 30 days
Lifetime
Comments
Experienced serious depression
Experienced serious anxiety or tension
Experienced hallucinations
Experienced trouble understanding, concentrating
or remembering
Experienced trouble controlling anger that led to
physical violence
Experienced serious thoughts of suicide
Attempted suicide
Been prescribed medication for any
psychological/emotional problem
Wanted to hurt or harm yourself (including selfmutilation)
Seriously wanted to hurt or harm someone else
Are there any life crises affecting you now? Yes
No
Please describe
Would you like to talk to someone about your feelings? Yes
No
Page 9
Last updated 4/27/10
Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Are you interested in counseling/therapy/support group? Yes
No
Have you ever received mental health or counseling services? Yes
Diagnosis?
No
If yes, name of provider
Are you currently receiving mental health? Yes
No
If yes, name of provider
Diagnosis?
Have you ever been hospitalized for mental health? Yes
No
If yes, please provide:
Date
Where Hospitalized
Reason
Duration
Are you taking medications for mental illness now or have you taken any medication in the past? Yes
No
Domestic Violence:
Have you ever been a victim of domestic violence (verbal, mental or physical) Yes
Are you currently involved in an abusive relationship? Yes
No
No
Community Resources and Support:
Does client’s have knowledge/understanding of available community resources?
Is the client currently receiving services? Yes
If yes, please list below:
Agency
Yes
No
No
Contact Name
Contact Number
Client’s primary source of emotional social support:
Name:
Services Received
Address:
Phone:
Comments:
Service
AIDS Clinical Trials
Budget Counseling
Needs
Receives
Page 10
Service
Advanced Directives
Burial Assistance
Needs
Last updated 4/27/10
Receives
Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Case Management
Clothing
Continuing education
Domestic Violence
Emergency Shelter
Employment
HIV Education
Home delivered Meals
Hospice Services
Information and Referral
Mental Health- Outpatient
Nutrition Supplements
Medicaid
Medical-Primary Care
Medicare
Partner Notification
Care Teams
Dental Care
Drug/Alcohol Treatment
Food Assistance
Food Stamps
Legal Assistance
Medical- HIV Specialty Care
Nutritional Counseling
Pharmacy Assistance
Post Test Counseling
Risk Reduction Counseling
Spiritual Support
SSI/SSDI
Support Groups
Treatment Adherence
Referrals to be made:
Summary:
Summarize information gathered from Assessment in a concise coherent manner. Essentially you are identifying
problems and concerns that became evident during your assessment. Please also include strengths, weaknesses that you
have identified in the client.
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Last updated 4/27/10
Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
I, ______________________________, certify that all the information I have given is true and accurate to the best of
my knowledge and belief. I agree to provide financial and other verification that may be needed to receive services.
Client (guardian) Signature_____________________________________________Date:_____________________
*Witness Signature (if needed):_________________________________________ Date: ______________________
Case Manager Signature_______________________________________________Date:_____________________
*If you do not have a third party witness available, to witness marks, please write a note of explanation and get your
supervisor to initial and date this form.
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