| 1 | IMRCDP3 ;HCIOFO/NCA - Display CDC Form (Cont.) ;7/16/97 08:55
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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 !,"| State/Country | | * Received clotting factor for hemophilia/coagulation disorder ............. |",$S(IMRPT:$$VAL^IMRCDCPX(15.9,1),1:1),"| |",$S(IMRPT:$$VAL^IMRCDCPX(15.9,0),1:0),"| |"
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| 5 | W $S(IMRPT:$$VAL^IMRCDCPX(15.9,9),1:9),"| |"
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| 6 | W !,"| | | Specify disorder: |",$S(IMRPT:$$VAL^IMRCDCPX(16.12,1),1:1),"| Factor VIII |",$S(IMRPT:$$VAL^IMRCDCPX(16.12,2),1:2),"| Factor IX |"
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| 7 | W $S(IMRPT:$$VAL^IMRCDCPX(16.12,8),1:8),"| Other |"
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| 8 | W !,"| FACILITY SETTING (check one) | | * (Hemophilia A) (Hemophilia B) (specify): "
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| 9 | S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,16.13,"E"),1:"") W X_$P(UNDR,"_",1,(15-$L(X)))," |"
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| 10 | W !,"| |",$S(IMRPT:$$VAL^IMRCDCPX(110.16,1),1:1),"| Public |",$S(IMRPT:$$VAL^IMRCDCPX(110.16,2),1:2),"| Private | | * HETEROSEXUAL relations with any of the following: |"
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| 11 | W !,"| |",$S(IMRPT:$$VAL^IMRCDCPX(110.16,3),1:3),"| Federal |",$S(IMRPT:$$VAL^IMRCDCPX(110.16,9),1:9),"| Unknown | | * Intravenous/injection drug user ........................................ |"
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| 12 | W $S(IMRPT:$$VAL^IMRCDCPX(16.22,1),1:1),"| |",$S(IMRPT:$$VAL^IMRCDCPX(16.22,0),1:0),"| |",$S(IMRPT:$$VAL^IMRCDCPX(16.22,9),1:9),"| |"
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| 13 | W !,"| | | * Bisexual male .......................................................... |",$S(IMRPT:$$VAL^IMRCDCPX(16.23,1),1:1),"| |",$S(IMRPT:$$VAL^IMRCDCPX(16.23,0),1:0),"| |"
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| 14 | W $S(IMRPT:$$VAL^IMRCDCPX(16.23,9),1:9),"| |"
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| 15 | W !,"| | | * Person with hemophilia/coagulation disorder ............................ |",$S(IMRPT:$$VAL^IMRCDCPX(16.24,1),1:1),"| |",$S(IMRPT:$$VAL^IMRCDCPX(16.24,0),1:0),"| |"
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| 16 | W $S(IMRPT:$$VAL^IMRCDCPX(16.24,9),1:9),"| |"
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| 17 | W !,"| FACILITY TYPE (check one) | | * Transfusion recipient with documented HIV infection .................... |",$S(IMRPT:$$VAL^IMRCDCPX(16.25,1),1:1),"| |",$S(IMRPT:$$VAL^IMRCDCPX(16.25,0),1:0),"| |"
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| 18 | W $S(IMRPT:$$VAL^IMRCDCPX(16.25,9),1:9),"| |"
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| 19 | W !,"| |",$S(IMRPT:$$VAL^IMRCDCPX(112.06,"01"),1:"01"),"| Physician,HMO | | * Transplant recipient with documented HIV infection ..................... |",$S(IMRPT:$$VAL^IMRCDCPX(110.03,1),1:1),"| |"
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| 20 | W $S(IMRPT:$$VAL^IMRCDCPX(110.03,0),1:0),"| |",$S(IMRPT:$$VAL^IMRCDCPX(110.03,9),1:9),"| |"
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| 21 | W !,"| |",$S(IMRPT:$$VAL^IMRCDCPX(112.06,31),1:31),"| Hospital,Inpatient | | * Person with AIDS or documented HIV infection, risk not specified ....... |"
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| 22 | W $S(IMRPT:$$VAL^IMRCDCPX(16.26,1),1:1),"| |"
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| 23 | W $S(IMRPT:$$VAL^IMRCDCPX(16.26,0),1:0),"| |",$S(IMRPT:$$VAL^IMRCDCPX(16.26,9),1:9),"| |"
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| 24 | W !,"| |",$S(IMRPT:$$VAL^IMRCDCPX(112.06,88),1:88),"| Other (specify): | | * Received transfusion of blood/blood components (other than clotting factor) |"
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| 25 | W $S(IMRPT:$$VAL^IMRCDCPX(16.14,1),1:1)
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| 26 | W "| |",$S(IMRPT:$$VAL^IMRCDCPX(16.14,0),1:0),"| |",$S(IMRPT:$$VAL^IMRCDCPX(16.14,9),1:9),"| |"
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| 27 | W !,"| " S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,102.1,"E"),1:"")
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| 28 | W X_$P(UNDR,"_",1,(22-$L(X)))," | | Mo. Yr. Mo. Yr.",?129,"|"
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| 29 | W !," | FIRST ",IMRFT," LAST ",IMRLT,?129,"|"
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| 30 | W !," | * Received transplant of tissue/organs or artificial insemination .......... |",$S(IMRPT:$$VAL^IMRCDCPX(102.14,1),1:1),"| |",$S(IMRPT:$$VAL^IMRCDCPX(102.14,0),1:0),"| |"
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| 31 | W $S(IMRPT:$$VAL^IMRCDCPX(102.14,9),1:9),"| |"
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| 32 | W !," | * Worked in a health-care or clinical laboratory setting ................... |",$S(IMRPT:$$VAL^IMRCDCPX(16.17,1),1:1),"| |",$S(IMRPT:$$VAL^IMRCDCPX(16.17,0),1:0),"| |"
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| 33 | W $S(IMRPT:$$VAL^IMRCDCPX(16.17,9),1:9),"| |"
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| 34 | W !," | (specify occupation): "
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| 35 | S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,16.18,"E"),1:"")
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| 36 | W X_$P(UNDR,"_",1,(15-$L(X))),?129,"|"
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| 37 | W !," ================================"
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| 38 | W "=============================================================="
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| 39 | D HDR^IMRCDCPR
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| 40 | Q
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