| 1 | IMRCDP7 ;HCIOFO/NCA - Display CDC Form (Cont.) ;7/16/97 08:58
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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 !," ================================================ IX. TREATMENT/SERVICES REFERRALS ============================================"
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| 5 | W !,"| Has this patient been informed of his/her HIV infection? |",$S(IMRPT:$$VAL^IMRCDCPX(110.06,1),1:1),"| Yes |"
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| 6 | W $S(IMRPT:$$VAL^IMRCDCPX(110.06,0),1:0),"| No |",$S(IMRPT:$$VAL^IMRCDCPX(110.06,9),1:9)
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| 7 | W "| Unk. | This patient is receiving or |"
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| 8 | W !,"| | has been referred for: Yes No Unk. |"
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| 9 | W !,"| This patient's partners will be notified about their HIV exposure and counseled by: | * HIV related medical services |"
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| 10 | W !,"| |",$S(IMRPT:$$VAL^IMRCDCPX(110.07,1),1:1),"| Health department |",$S(IMRPT:$$VAL^IMRCDCPX(110.07,2),1:2),"| Physician/provider |"
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| 11 | W $S(IMRPT:$$VAL^IMRCDCPX(110.07,3),1:3)
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| 12 | W "| Patient |",$S(IMRPT:$$VAL^IMRCDCPX(110.07,9),1:9),"| Unknown | * Substance abuse treatment services |"
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| 13 | W !?1,LN
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| 14 | W !,"| This patient received or is receiving: | This patient has been enrolled at: | This patient's medical treatment is |"
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| 15 | W !,"| * Anti-retroviral Yes No Unk. | Clinical Trial Clinic | PRIMARILY reimbursed by: |"
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| 16 | W !,"| therapy",?24,"|",$S(IMRPT:$$VAL^IMRCDCPX(110.08,1),1:1),"| |",$S(IMRPT:$$VAL^IMRCDCPX(110.08,0),1:0),"| |"
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| 17 | W $S(IMRPT:$$VAL^IMRCDCPX(110.08,9),1:9),"| | |",$S(IMRPT:$$VAL^IMRCDCPX(110.1,1),1:1)
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| 18 | W "| NIH-sponsored |",$S(IMRPT:$$VAL^IMRCDCPX(110.11,1),1:1),"| HRSA-sponsored | |"
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| 19 | W $S(IMRPT:$$VAL^IMRCDCPX(110.12,1),1:1),"| Medicaid |",$S(IMRPT:$$VAL^IMRCDCPX(110.12,2),1:2),"| Private ins/HMO |"
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| 20 | W !,"| | |",$S(IMRPT:$$VAL^IMRCDCPX(110.1,2),1:2),"| Other |",$S(IMRPT:$$VAL^IMRCDCPX(110.11,2),1:2)
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| 21 | W "| Other | |",$S(IMRPT:$$VAL^IMRCDCPX(110.12,3),1:3),"| No coverage |",$S(IMRPT:$$VAL^IMRCDCPX(110.12,4),1:4),"| Other public funds |"
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| 22 | W !,"| Yes No Unk. | |",$S(IMRPT:$$VAL^IMRCDCPX(110.1,3),1:3),"| None |"
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| 23 | W $S(IMRPT:$$VAL^IMRCDCPX(110.11,3),1:3),"| None | |",$S(IMRPT:$$VAL^IMRCDCPX(110.12,7),1:7)
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| 24 | W "| Clinical |",$S(IMRPT:$$VAL^IMRCDCPX(110.12,9),1:9),"| Unknown |"
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| 25 | W !,"| * PCP prophylaxis |",$S(IMRPT:$$VAL^IMRCDCPX(110.09,1),1:1),"| |",$S(IMRPT:$$VAL^IMRCDCPX(110.09,0),1:0),"| |"
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| 26 | W $S(IMRPT:$$VAL^IMRCDCPX(110.09,9),1:9),"| | |"
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| 27 | W $S(IMRPT:$$VAL^IMRCDCPX(110.1,9),1:9),"| Unknown |",$S(IMRPT:$$VAL^IMRCDCPX(110.11,9),1:9),"| Unknown | trial/government program |"
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| 28 | W !?1,LN
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| 29 | W !,"| FOR WOMEN: *This patient is receiving or has been referred for gynecological or obstetrical services: . |"
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| 30 | W $S(IMRPT:$$VAL^IMRCDCPX(110.13,1),1:1),"|Yes |",$S(IMRPT:$$VAL^IMRCDCPX(110.13,0),1:0),"|No |"
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| 31 | W $S(IMRPT:$$VAL^IMRCDCPX(110.13,9),1:9),"|Unk |"
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| 32 | W !,"| *Is this patient currently pregnant? ....................................................... |"
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| 33 | W $S(IMRPT:$$VAL^IMRCDCPX(110.14,1),1:1),"|Yes |",$S(IMRPT:$$VAL^IMRCDCPX(110.14,0),1:0),"|No |",$S(IMRPT:$$VAL^IMRCDCPX(110.14,9),1:9),"|Unk |"
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| 34 | W !,"| *Has this patient delivered live born infants? ... |",$S(IMRPT:$$VAL^IMRCDCPX(110.15,1),1:1),"|Yes (If delivered after 1977, provide birth |"
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| 35 | W $S(IMRPT:$$VAL^IMRCDCPX(110.15,0),1:0),"|No |",$S(IMRPT:$$VAL^IMRCDCPX(110.15,9),1:9),"|Unk |"
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| 36 | W !,"|",?73,"information below for the most recent birth) |"
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| 37 | W !?1,LN
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| 38 | W !,"| CHILD'S DATE OF BIRTH: | Hospital of Birth: "
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| 39 | S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,112.02,"E"),1:"") W X_$P(UNDR,"_",1,(23-$L(X)))," | Child's Soundex: | Child's State Patient No. |"
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| 40 | W !,"| Mo. Day Yr. | | | | | | | __________ | | | | | | | | | | | | |"
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| 41 | W !,"| " S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,112.01,"I"),1:"")
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| 42 | I X'="" S X=$E(X,4,5)_" "_$E(X,6,7)_" "_$E(X,2,3)
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| 43 | W $S(X="":" ",1:X)," | City: " S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,112.03,"E"),1:"") W X_$P(UNDR,"_",1,(23-$L(X)))," State: "
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| 44 | S X=$S(IMRPT:$$FIELD^IMRCDCPX(158,IMRPT,112.04,"E"),1:"") W X_$P(UNDR,"_",1,(3-$L(X)))," |",?99,"|",?129,"|"
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| 45 | D HDR^IMRCDCPR
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| 46 | Q
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