IFHC Encounter Data Entry Form
HEALTH CENTER #
SERVICES PROVIDED (check all applicable)
CLIENT NUMBER #
DATE OF VISIT
/
/ 2013
FIPS CODE
RACE (check all that apply)
 1. White
 5. Unknown/Not Reported
 2. Black
 7. Native Hawaiian/Pacific Islander
 3. American Indian/Alaska Native
 4. Asian
ETHNIC ORIGIN - Hispanic
 Yes
 No
 Unknown
INTERPRETER/BILINGUAL STAFF NEEDED
 1. Yes
 2. No
GENDER (check one)
 Female
 Male
PREGNANCY HISTORY (female only)
a. Number of previous pregnancies: ___________
b. Number of live births: ___________________
d. Age at first pregnancy: __________________
e. Age at first live birth: ___________________
f.
Last pregnancy ended (mo./yr.):
____ / _____
mm YYYY
PREGNANCY DESIRED WITHIN 1 YEAR?
 Yes
 No
EMPLOYMENT STATUS
 1. Employed – Full Time
 2. Employed – Part Time
 3. Unemployed
 4. Not Seeking Work
CURRENTLY IN SCHOOL?
 Yes
 No
EDUCATIONAL LEVEL (last grade completed)
 1. Grade 1-8
 2. Grade 9-12
 3. GED/HS Diploma
 4. Grad. School 17-20
 5. Undergrad/Tech School 13-16
 6. Unknown/None
PURPOSE OF VISIT (check one)
 1. Initial Comprehensive
 2. Annual Comprehensive
 9. Other Comprehensive
 8. Medical Problem
 6. Post Partum
DATE OF BIRTH
/
INCOME AND FAMILY SIZE
 5. Deferred
 3. Routine Medical
 4. Education/Counseling
 7. Emergency Contraception
/
Monthly Family Income? ___________
Family Size? _______________
PRIMARY SOURCE OF PAYMENT (check one)
 1. Medicaid Only
 2. No Fee
 3. Partial Fee
4. Full Fee
 6. Private Insurance
 8. ADV
 9. Other
10. CHIP
INSURANCE (check one)
 1. Private w/BC coverage
 2. Private w/o BC coverage
 3. Medicaid/Public
 4. Private/ BC coverage Unknown
 5. Uninsured
 6. Unknown
 01. Blood Pressure
 30. Wet Mount
 02. Height/Weight
 64. HSV Test
 03. Thyroid Palp
 63. Urine Pregnancy Test
 04. Heart/Lung Aus
 43. Negative Preg. Test
 05. Breast Exam
 44. Positive Preg. Test
 06. Abdominal Palp
 67. Contraceptive Injection
 07. Extremities
 57. IUD Insert
 08. Bimanual Pelvic
 58. IUD Removal
 09. Speculum Exam
 89. HPV vaccine
 11. Female External Genitalia  34. Other Lab or Exam
 10. Male Genitalia
 45. Treatment: Gonorrhea
 18. Post Abortion Check
 50. Treatment: Chlamydia
 19. Postpartum Check
 61. Treatment: Cervicitis
 20. Hgb
 46. Treatment: PID
 22. HIV Test
 52. Treatment: Wart
 88. HIV WB Results Given
 62. Treatment: HSV
 23. Syphilis Test
 49. Treatment: Vaginitis
 24. Urine Dipstick
 66. Treatment: UTI
 25. Pap Smear
 72. Treatment: Anemia
 26. Repeat Pap Smear
 95. Treatment: Urethritis
 28. Gonorrhea/CT Test
COUNSELING EDUCATION PROVIDED (check all applicable)
 01. Contraceptive
 18. HIV Post Test
 02. NFP
 11. Other
 04. Infertility
 19. Exercise/Nutrition
 05. Smoking/Tobacco
 13. Abstinence
 06. Alcohol/Drug Abuse
 15. Crisis
 07. Pregnancy
 16. Abnormal Pap
 08. PCC/Folic Acid
 17. Domestic Violence
 09. STD/HIV Prevention
 20. SBE
 10. HIV Pre Test
 21. Adolescent Counseling
BMI
BMI EDUCATION?
 1. <18.5
 4. 30-39.9
 YES
 2. 18.5-24.9
 5. 40 and above
 NO
 3. 25-29.9
CIGS/DAY
SERVICE PROVIDER
 1. <5
 5. NONE
 1. Physician
 2. 5-10
 2. PA, NP, CNM
 3. 11-20
 3. Other Clinical Staff
 4. >20
 4. Non-Clinical Staff
CONTRACEPTIVE METHOD
15. Abstinence
02. IUD
09. Sterilization
05. Condom
07. Natural Method
19. Vaginal Ring
14. Depo Provera Inj 13. None
20. Vasectomy
03. Diaphragm
11. Other
21. Female Condom
16. ECP
18. Patch
01. Oral
06. Spermicide
04. Foam & Condom 10. Sponge
12. Hormone Implant
CONT. BEFORE:______ CONT. AFTER: ______
WHY NO METHOD?
 1. Pregnancy Planned
 4. Other Medical Reason
 9. Pregnancy Unplanned
 6. Other
 2. Infertility
 8. Refused
 3. Seeking Pregnancy
CONDOMS:
 Yes  No
ECP FUTURE USE:
 Yes  No
REFERRALS (check all applicable)
 01. Sterilization
 15. Mammogram
 02. Gynecology
 08. Other Medical
 03. Prenatal
 05. Social Services
 16. Abortion
 11. Nutrition
 06. Contraception
 12. Other
 10. Infertility
 17. Breast
 07. STD
 18. Adoption
 14. HIV
HIV RESULTS
HIV WB F/U RESULTS
 1. Negative
 1. Confirmed Pos
 2. Invalid
 2. Confirmed Neg
 3. Prel + Serum WB
 3. Indeterminate
 4. Prel + OraSure
 5. Pending
IFHC 4/29/11, rev. 9/11, 1/12, 1/13
IFHC Encounter Data Entry Form
IFHC 4/29/11, rev. 9/11, 1/12, 1/13