Clinical Manual > Testing and Assessment > Initial History

Initial History

July 2006

Chapter Contents

Table 1. Patient Information

Table 2. Initial History Checklist

Table 3. Review of Systems

Background

This chapter includes essential points to cover during an initial clinic intake visit.

Conducting a thorough initial history and physical examination is important even if previous medical records are available. This is the best opportunity to get a complete picture of the patient's HIV disease status and his or her physical and emotional condition, as well as to establish the basis for an ongoing relationship with the patient. Many of the conditions that put immunocompromised patients at risk for disease can be detected early, by means of a thorough assessment.

The information gathered through the initial history and physical examination will provide a comprehensive standardized database for the assessment and treatment of HIV-related problems, including acute intervention and ongoing supportive care. For essential aspects of the physical examination to cover in an initial clinic intake visit, see chapter Initial Physical Examination .

O: Objective

Document the patient's full name, date of birth, date of assessment, and any other information standard to your practice (Tables 1 and 2). Perform a review of systems ( Table 3 ).

Table 1. Patient Information

First Name:	Last Name:
Date of Birth: ____ / ____ / ______	Date of Assessment: ____ / ____ / ______

Table 2. Initial History Checklist

Category / Subject Matter	Questions
Key to abbreviations : ARV = antiretroviral; HPV = human papillomavirus; MAC = Mycobacterium avium complex; PCP = Pneumocystis jiroveci pneumonia; PPD = purified protein derivative; TB = tuberculosis.
History of Present Illness
HIV Testing	What was the date of your positive HIV test?
	Did you have a previous test? If so, when was the last negative HIV test?
	When do you think you were infected?
Treatment Status	Where do you usually receive your health care?
	Have you ever received care for HIV?
	What was the date of your last HIV care visit?
	Do you know what your first CD4 (T-cell) count was?
	What was your lowest CD4 count?
	What was your highest CD4 count?
	What is your current CD4 count?
	Do you know what your first viral load count was?
	What was your highest viral load count?
	What was your lowest viral load count?
	What is your current viral load count?
	Have you participated in any research protocols?
	Would you be interested in participating?
Risk for HIV and Other Sexually Transmitted Diseases	How do you think you were exposed to HIV?
Sexual	Please tell me about any experience you've had with unprotected anal, vaginal, or oral sex.
	Have you had sex with men? With women?
	Have any of your sex partners:
	Told you they were HIV infected or had AIDS?
	Told you they used injection drugs?
	Ever been in jail or prison?
	Had a sexually transmitted disease?
	Had hemophilia?
	Received a blood transfusion?
	Have you ever received donated sperm during artificial insemination?
Substance Use	Please tell me about your experience with injected substances.
Substance Use	Have you shared your needles or injection equipment (works) with another individual?
Transfusion	Did you receive any blood or blood products between 1977 and 1985?
Occupational	Have you had an on-the-job injury that involved contact with a body fluid?
Occupational	What was the injury, and was HIV evaluation a part of the work injury follow-up?
Tattoos	Do you have any tattoos?
Tattoos	Were sterile needles and ink-wells used to place your tattoo?
HIV-Related Illnesses	What opportunistic infection(s) have you had, if any? (PCP, MAC, cryptococcal meningitis, TB, etc)
	What year(s) were you diagnosed with the above?
	Have you had cancer(s)?
	What other HIV-related illnesses have you had?
Active Tuberculosis (TB) and TB Testing History	When was your last TB skin test (PPD)?
	What were the results of this test?
	Have you ever had a positive TB skin test?
	What year and what health care setting?
	What medications did you take and for how long?
	Have you ever had active tuberculosis?
Medications	Are you taking HIV medications now?
	If so, can you name them or describe them, and give their dosing frequency?
	How many doses have you missed in the last 3 days? The last week? The last month?
	What HIV medicines have you taken in the past (names or descriptions)? [If possible, have patient list all ARVs and ARV combinations, with dates and corresponding CD4 counts and viral loads.]
	When did you start and stop them (dates)?
	Do you know why you stopped these medications?
	Do you know what your HIV viral load or your CD4 counts were while you were taking your medications?
	Have you ever had a resistance test done?
	What other medications are you taking now?
	What herbs, over-the-counter (OTC) products, or vitamins are you taking now?
Past Medical and Surgical History
Chronic Diseases	Do you have any chronic conditions, such as diabetes, high blood pressure, heart disease, cholesterol problems, asthma, emphysema, sickle cell disease, ulcers, acid reflux, irritable bowel syndrome, thyroid disorders, kidney or liver problems, or mental health disorders?
Chronic Diseases	If so, do you receive medical care for these conditions?
Previous Illnesses	Have you had any hospitalizations? Where, when, and for what reason?
	Have you had any surgeries? When and where?
	Have you had any major illnesses, including mental health conditions?
Hepatitis	Have you ever had hepatitis? What type (A, B, C)?
	Do you have chronic hepatitis?
	Do you know your immunity status to hepatitis A or hepatitis B? Have you been vaccinated?
Gynecologic	When was your last Papanicolaou (Pap) smear?
	What were the results?
	Have you ever had an abnormal Papanicolaou (Pap) smear?
	When was your last menstrual period?
	What is the usual length of your cycle?
	Have you noticed changes in your menstrual cycle?
	Have you had any lower abdominal pain?
	Do you get yeast infections? How often?
	Do you get urinary infections?
	Have you ever had kidney stones?
Obstetric	How many pregnancies have you had?
	How many miscarriages or therapeutic abortions?
	How many live births? Ages of children now?
	Was HIV tested during any pregnancy?
	Did you deliver an infant while you were HIV infected?
	Was HIV medication given during pregnancy and delivery?
	Do you have children who are HIV infected?
	Do you intend to become pregnant?
Anorectal History	Have you ever had an anal Papanicolaou (Pap) smear?
Anorectal History	What were the results?
Sexually Transmitted Infections (STIs)	Have you ever been treated for:
	Syphilis?
	Vaginitis?
	Genital herpes?
	NGU (nongonococcal urethritis)?
	Gonorrhea?
	Genital warts (HPV)?
	Chlamydia?
	Proctitis?
	Pelvic inflammatory disease (PID)?
Health-Related Behaviors	Do you smoke? How long have you smoked? How many cigarettes per day?
	Do you smoke anything besides tobacco?
	Do you chew tobacco?
	How much alcohol do you drink?
	Any experience with blackouts due to alcohol?
	Do you use any street drugs we haven't covered in earlier questions?
	If so, what drugs and how do you use them (inject, smoke, inhale, etc)?
	When did you last inject a substance?
	How about inhaled or snorted substances?
	Have you shared your equipment with another person?
	When did you last inhale a substance?
	Or smoked substances?
	Have you shared your equipment?
	When did you last smoke a substance?
	Are you interested in treatment for alcohol or drug use?
	What pain relievers do you use on a regular basis?
Immunizations	When was your last vaccination for:
	Tetanus?
	Streptococcal pneumonia (Pneumovax)?
	Influenza?
	Hepatitis A?
	Hepatitis B?
	Did you have chickenpox as a child, or were you vaccinated against chickenpox?
	What about measles, mumps, and rubella?
Allergies	What allergies do you have to medications?
	What was the reaction?
	What allergies to foods or environmental substances?
Family History
	Do you have a family history of:
	Heart disease? Heart attacks or strokes?
	Cholesterol problems? Diabetes?
	Cancer?
	Mental health conditions (such as depression, anxieties, phobias)?
	Addictions?
	Which family member(s) and what is their health status currently?
Social History
Relationship Situation	What is your relationship status (single, married, partnered, divorced, widowed)?
Relationship Situation	Do you have children?
Living Situation	Do you live alone or with others? With whom?
Support System	Who knows about your HIV status?
	Which individual is the most supportive of your HIV diagnosis?
	Who is the least supportive of your status?
	Have you used any community support services such as support groups?
Employment	Are you currently employed?
	Where do you work?
	Describe your job task(s).
	What setting do you work in on a daily basis?
	Does your employer provide health insurance?
	If on disability: How long have you been on disability?
	What medical condition has made you disabled?
Travel	Where have you traveled outside the United States?
Travel	When did travel take place?
Diet	Tell me what you eat during a typical day.
	Do you consume raw (unpasteurized) milk, raw eggs, raw or rare meat, deli meats, soft cheeses, or raw fish?
	How much water do you drink during the day?
	What is your source of water?
	How much caffeine do you drink during a typical day?
Pets	Do you have or have you had any pets?
Pets	What kind of pets, and who cleans up after them?
Exercise	What kind of physical exercise and recreational activity do you participate in?
Exercise	How often?
Sensitive Sexual History Questions
General Sexual	Do you have sex with men, women, or both?
General Sexual	In the past, have you had sex with men, women, or both?
Sexual Identity	Do you consider yourself male or female?
	Have you had or considered treatment for sex change?
	Have you had hormone therapy?
	Have you had any sex-change surgery?
Sexual Practices	Do you have anal, vaginal, and/or oral sex?
	Do you protect yourself from sexually transmitted infections, or HIV reinfection? How?
	For men who have sex with men: Are you the receptive or insertive partner, or both?
	How often do you use alcohol or drugs before or during sex?
Prevention	Do you know the HIV status of your partner(s)?
	Do you protect your partners from HIV? How?
	In what situations do you or your partner use condoms or some other barrier?
Sex Trading	Have you ever exchanged sex for food, shelter, drugs, or money?
Contraception	What birth control measures do you use, if any?
	Do you use condoms or other latex barriers?
	Do you have plans for you or your partner to become pregnant?
Mental Health
Coping	How do you handle your problems/stresses?
Coping	What do you do to relax?
Therapy	Have you thought about seeing a mental health provider?
	Have ever been diagnosed with depression, anxiety, panic, bipolar disorder, etc?
	Have you taken or are you taking any medications for these conditions?
	Are you seeing a therapist or mental health professional?
	Have you had any previous counseling or mental health problems?
	Have you ever been hospitalized for a psychiatric condition?
	Have you ever thought about hurting yourself? If yes, probe for previous suicide attempts: Are you feeling that way now? (See chapter Suicidal Ideation and prepare for immediate referral if necessary.)
Violence	Have you ever been sexually abused, assaulted, or raped?
	In your adult life, have you lived in any situation with physical violence or intimidation?
	When has this occurred?
	Are you afraid for your safety now?
Childhood Trauma	Who reared you (one or both parents, other relatives, foster care)?
	Was there any alcoholism or drug abuse in your household when you were a child?
	Did you experience or observe violence; physical, sexual, or emotional abuse; or neglect?

Table 3. Review of Systems

For each positive answer, document location, characteristics, duration of symptoms, and exacerbating and alleviating factors.
General
General	Do you ever wake up feeling tired?
Fever	Do you have fevers? How high, and for how long?
Night Sweats	Do you ever sweat so much at night that it soaks your sheets and nightclothes?
Chills	Do you experience shaking or teeth-chattering when you feel cold?
Anorexia	How is your appetite?
Weight	What was your weight 1 year ago?
	What is a normal weight for you?
	Have you lost or gained weight unintentionally?
Body Changes	Have you noticed any changes in the shape of your body (describe)? For example, has there been an increase in your waist, collar, or breast size or a decrease in your arm, leg, or buttocks size?
	Have you noticed increased visibility of veins in your arms and legs?
	Have you noticed thinning of your face?
Head, Ears, Eyes, Nose, and Throat
Vision	Have you noticed any changes in your vision, especially blurred vision or vision loss, double vision, new "floaters" or flashes of light?
	Have you noticed this problem in one or both eyes?
	When did you first notice these changes?
Mouth, Ears, Nose, Throat	Have you noticed any white spots in your mouth or a white coating on your tongue (thrush, oral hairy leukoplakia)?
	Do you ever get sores in your mouth or the back of your throat? Gum problems?
	Any nosebleeds?
	Hearing loss, ringing in your ears, ear pain?
Cardiovascular
Cardiac	Any palpitations or chest pain?
	Any shortness of breath during activities or while you are lying down?
	How far can you walk or run before you get short of breath?
	Any swelling in feet or hands?
Pulmonary
Cough	Do you have a cough?
Cough	Can you describe it? Dry or productive, amount, color, odor, presence of blood in sputum? When is it the worst?
Dyspnea	Do you ever feel short of breath?
	Does that happen when you are sitting still, lying down, or moving around?
	How severe is your shortness of breath?
	Does it prevent you from doing anything?
	Do you ever wheeze?
Gastrointestinal
Dysphagia	Do you have any problems with food sticking in your throat or being difficult to swallow?
	Do you notice it's easier to swallow liquids or solids?
	Do you gag or get nauseated when trying to eat?
Odynophagia	Do you have pain in your throat, esophagus, or behind your breastbone when you swallow?
Nausea/Vomiting	Do you have nausea or vomiting?
Nausea/Vomiting	When? Are there specific things that cause this?
Dyspepsia/Reflux	Do you ever have heartburn?
	When does it happen--after eating, lying down, on an empty stomach?
	Do you get the taste of stomach acid in your mouth?
Diarrhea	Do you have diarrhea, or more than 3-5 unformed stools a day?
	Stool characteristics: bloody, pus, mucus?
	Pain or cramping with diarrhea? Tenesmus?
Bowel Habits	How frequently do you have bowel movements?
	Do you have problems with constipation, blood in the stools, or other?
	Do you have problems with flatulence or belching after eating?
Genitourinary
Genital	Do you have any lesions or sores on your genital area now, or have you in the past?
	Have you ever had genital herpes? If yes, how often do you have outbreaks?
	When was the most recent outbreak?
Women	Have you had any lower abdominal pain?
	Have you noticed a vaginal discharge or odor?
	Do you have any burning or pain on urination?
	Frequent urination?
	Do you lose control of your urine or have problems getting to the bathroom before you start to urinate?
Men	Have you noticed any swelling or testicular pain?
	Do you have difficulty starting your stream of urine?
	Are you getting up at night to urinate?
	Have you had burning or pain on urination?
	Do you lose control of your urine or have problems getting to the bathroom before you start to urinate?
	Have you ever had kidney stones?
	Do you have any difficulty developing an erection or maintaining one?
	Any discharge from your penis?
Musculoskeletal
	Do you have any muscle aches or pains?
	Back pain, joint pain, and/or swelling?
	Have you ever broken any bones?
	Do you have chronic pain?
	Describe the pain--location, duration, rating (scale of 1-10), alleviation factors.
Skin
Herpes Zoster	Have you ever had chickenpox (varicella)?
	Have you ever had "shingles" (zoster)?
	Where were the lesions?
Tinea	Do you have fungal infections on your skin, especially groin, fingernails, toenails, or feet?
Folliculitis	Do you have any itchy bumps on your face, back, or chest?
Seborrhea	Do you have flaking or itching on your skin or scalp?
Skin Lesions	Have you noticed any rash or skin problems? If so, where?
	Have you noticed any new moles, bruises, or bumps on your skin?
	Do you have any moles that changed shape, size, or color?
Neurologic
Headache	How often do you get headaches?
	Describe the headaches--location, timing, duration, alleviating or aggravating factors.
	Do they cause nausea or vomiting?
	Does sensitivity to light lead to headaches?
Memory	Do you have difficulty with your memory or ability to concentrate? If so, describe.
Gait	Have you noticed any changes in the way you walk?
Neuropathy	Do you have any numbness, tingling, burning, or pain in your hands or feet?
Seizures	Have you ever had a seizure or "fit"?
Seizures	If so, describe the seizure--When? How long did it last? Loss of consciousness? Was medical care sought?
Weakness	Do you have or have you had any weakness in your arms or legs?
Endocrine
Diabetes	Have you had any increase in thirst, hunger, or urination?
Thyroid	Have you noticed changes in your energy level?
	Do you have intolerance to heat or cold?
	Have you noticed changes in your hair (thinning, coarse texture)?
Sex Steroids	Have you noticed any changes in your libido?
Hematologic/Lymphatic
Adenopathy	Do you have swollen glands?
Adenopathy	If so, describe--location, painful, size if measurable.
Bruising or Bleeding	Have you noticed easy bruising or prolonged bleeding after injury?
Bruising or Bleeding	Nosebleeds or bleeding gums?
Psychiatric
Mood	Depression screening: Have you experienced a decrease in your interest or pleasure in your activities? Have you felt depressed, down, or hopeless?
	Do you feel more angry, sad, depressed, numb, irritable, or anxious than usual?
	Have any major life events have occurred to cause you to feel sad or depressed?
	When did these events occur?
Sleep	How is your sleep?
	How many hours do you sleep each night?
	What is your sleeping schedule--time to bed and time to rise?
	Do you take naps?

A: Assessment and Plan

Conduct a physical examination, focusing on subjective findings elicited in the history. (See chapter Initial Physical Examination .) Note: If significant time has elapsed between the ROS and physical exam, perform another ROS.
Compose a problem list. Initiate a medication list (if appropriate).
Order baseline/intake laboratory work. (See chapter Initial and Interim Laboratory and Other Tests .)
Refer the patient to social services, mental health, community and other resources, or other clinic services as needed.

During today's visit or a future visit:

Perform PPD testing if not done in the last year, or if the patient was previously PPD negative. The patient can return to have the PPD read.
Perform immunizations for pneumonia (Pneumovax), influenza (as appropriate), and other immunizations as indicated. (See chapter Immunizations for HIV-Infected Adults and Adolescents .)
Provide counseling on prevention of HIV transmission (eg, safer sex and injection practices), as appropriate.

References

Aberg, Gallant, et al. Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America . Clin Infect Dis 2004 Sep 1;39(5):609-29. Available online at www.journals.uchicago.edu/CID/.

Bartlett JG, Cheever L. A Guide to Primary Care of People with HIV/AIDS , 2004 Edition. Rockville, MD: Department of Health and Human Services, HIV/AIDS Bureau. 2004. Available online at hab.hrsa.gov/tools/primarycareguide/.

Bartlett JG, Gallant JE. 2005-2006 Medical Management of HIV Infection . Baltimore: Johns Hopkins University Division of Infectious Diseases; 2005. Available online at hopkins-aids.edu/mmhiv/order.html.

Hollander H. Initiating Routine Care for the HIV-Infected Adult. In: Sande MA, Volberding PA, eds. The Medical Management of AIDS, 5th ed. Philadelphia: WB Saunders; 1997:107-112.

U.S. Public Health Service, Infectious Diseases Society of America. 2002 Guidelines for preventing opportunistic infections among HIV-infected persons--2002 . MMWR Recomm Rep. 2002 Jun 14;51(RR08);1-46. Available online at aidsinfo.nih.gov/Guidelines/. Accessed May 19, 2006.

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