| [613] | 1 | IMRCDP2 ;HCIOFO/NCA - Display CDC Form (Cont.) ;7/16/97 08:54
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| 2 | ;;2.1;IMMUNOLOGY CASE REGISTRY;;Feb 09, 1998
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| 3 | Q:IMRUT
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| 4 | W !,"AT REPORT (check one): | Mo. Day Yr. |"
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| 5 | W " Alive Dead Unk. | Mo. Day Yr. |",!,"|",$S(IMRPN:$$VAL^IMRCDCPX(110.01,1),1:1),"| HIV Infection (not AIDS) "
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| 6 | S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,110.02,"E"),1:0) S:X'>0 X="__" W X," Years | | | |"
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| 7 | W !,"|",$S(IMRPT:$$VAL^IMRCDCPX(110.01,2),1:2),"| AIDS " S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,15.8,"I"),1:0) S:X'>0 X="__" W X," Years | ",IMRDOB
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| 8 | W " | |",$S(IMRPT:$$VAL^IMRCDCPX(15.7,1),1:1),"| |",$S(IMRPT:$$VAL^IMRCDCPX(15.7,2),1:2),"| |",$S(IMRPT:$$VAL^IMRCDCPX(15.7,9),1:9),"| | ",IMRDOD," | ",$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,112.05,"E"),1:"")
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| 9 | W !,"----------------------------------------------------------------------------------------------------------------------------------"
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| 10 | W !,"SEX: |RACE/ETHNICITY: |COUNTRY OF BIRTH: "
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| 11 | W !,"|",$S(IMRPT:$$VAL^IMRCDCPX(1.2,1),1:1),"| Male ||",$S(IMRPT:$$VAL^IMRCDCPX(1,1),1:1),"| White (not Hispanic) |",$S(IMRPT:$$VAL^IMRCDCPX(1,2),1:2),"| Black (not Hispanic) |",$S(IMRPT:$$VAL^IMRCDCPX(1,3),1:3)
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| 12 | W "| Hispanic "
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| 13 | W "||",$S(IMRPT:$$VAL^IMRCDCPX(102.08,1),1:1),"| U.S. |",$S(IMRPT:$$VAL^IMRCDCPX(102.08,7),1:7),"| U.S. Dependencies and Possessions (in-"
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| 14 | W !,"|",$S(IMRPT:$$VAL^IMRCDCPX(1.2,2),1:2),"| Female ||",$S(IMRPT:$$VAL^IMRCDCPX(1,4),1:4),"| Asian/Pacific |",$S(IMRPT:$$VAL^IMRCDCPX(1,5),1:5),"| American Indian/ |",$S(IMRPT:$$VAL^IMRCDCPX(1,9),1:9)
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| 15 | W "| Not | cluding Puerto Rico (specify): "
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| 16 | S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,102.23,"E"),1:""),UNDR="______________________________"
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| 17 | W X_$P(UNDR,"_",1,(15-$L(X)))
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| 18 | W !," | Islander Alaskan Native Specified ||",$S(IMRPT:$$VAL^IMRCDCPX(102.08,8),1:8),"| Other (specify): "
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| 19 | S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,16.1,"E"),1:"") W X_$P(UNDR,"_",1,(15-$L(X)))," |",$S(IMRPT:$$VAL^IMRCDCPX(102.08,9),1:9),"| Unknown"
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| 20 | W !,"----------------------------------------------------------------------------------------------------------------------------------"
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| 21 | W !,"RESIDENCE AT DIAGNOSIS:",?48,"State/"
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| 22 | W !,"City: ",$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPN,16.2,"E"),1:""),?25,"County: ",$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,16.3,"E"),1:""),?48,"Country: "
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| 23 | S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,16.4,"E"),1:"") I X="" S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,16.5,"E"),1:"") W X
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| 24 | W ?92,"Zip Code: " S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPN,16.6,"E"),1:"") W X
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| 25 | W !,"----------------------------------------------------------------------------------------------------------------------------------"
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| 26 | W !,"- IV. FACILITY OF DIAGNOSIS ---- --------------------------------------- V. PATIENT HISTORY -----------------------------------"
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| 27 | W !,"|" S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPN,16.7,"E"),1:"")
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| 28 | W X_$P(UNDR,"_",1,(28-$L(X)))," | | AFTER 1977 AND PRECEDING THE FIRST POSITIVE HIV ANTIBODY TEST |"
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| 29 | W !,"| FACILITY NAME: | | OR AIDS DIAGNOSIS, THIS PATIENT HAD (Respond to ALL Categories): Yes No Unk. |"
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| 30 | W !,"| " S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPN,16.8,"E"),1:"") W X_$P(UNDR,"_",1,(28-$L(X)))," | | * Sex with male " W "............................................................ "
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| 31 | W "|",$S(IMRPT:$$VAL^IMRCDCPX(17.8,1),1:1),"| |",$S(IMRPT:$$VAL^IMRCDCPX(17.8,0),1:0),"| |",$S(IMRPT:$$VAL^IMRCDCPX(17.8,9),1:9),"| |"
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| 32 | W !,"| City | | * Sex with female .......................................................... "
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| 33 | W "|",$S(IMRPT:$$VAL^IMRCDCPX(17.9,1),1:1),"| |",$S(IMRPT:$$VAL^IMRCDCPX(17.9,0),1:0),"| |",$S(IMRPT:$$VAL^IMRCDCPX(17.9,9),1:9),"| |"
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| 34 | W !,"| " S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,16.9,"E"),1:"") I X="" S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,16.11,"E"),1:"")
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| 35 | W X_$P(UNDR,"_",1,(28-$L(X)))," | | * Injected nonprescription drugs ........................................... |",$S(IMRPT:$$VAL^IMRCDCPX(16.19,1),1:1),"| |",$S(IMRPT:$$VAL^IMRCDCPX(16.19,0),1:0),"| |"
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| 36 | W $S(IMRPT:$$VAL^IMRCDCPX(16.19,9),1:9),"| |"
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| 37 | D HDR^IMRCDCPR
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| 38 | Q
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