Name:
URN#:
DOB:
Sex:
RYAN WHITE PROGRAM PART A
Charlotte Transitional Grant Area (TGA)
Case Management Assessment Tool
General:
Agency ID #: Date of Assessment: _________
Client’s full name:
Location of Assessment:
Was information obtained during the assessment provided by person(s) in addition to the client? Yes No
If yes who? Relationship: Phone:
********************************************************************************************
Please refer to original intake and assessment for any demographic information.
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Education:
Educational level: Grade School High School/GED Associates Degree
Undergraduate Degree Graduate/Post Grad. Degree
Reading Ability/Literacy: High Moderate Limited
Race/Ethnicity:
Race: African American/Black Latino/Hispanic
Asian/Pacific Islander Native American
Black/Non-Hispanic White/Non-Hispanic
Other:
Housing:
Apartment/Condo House Mobile Home Group Home Transitional Homeless
Rent Own Other
Also check one of the following: Permanent (stable) Non-Permanent
Current Housing Programs: HOPWA Section 8 Housing Authority
None Unknown Other:
Does the client have any physical impairments/limitations that affect his/her safety in the home?
Yes No If yes, please describe
Are there any structural or functional inadequacies in the client’s home?
Yes No If yes, please describe
Adequate Overcrowded Criminal Activity No Indoor Plumbing
Substandard Unaffordable Threat of Physical Violence Other:
Unknown
Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Make any other comments about the client’s home environment you have observed that may have an effect on his/her
ability to function independently
Are there other persons (Adults/Non-dependent Children) in the household? Yes No
If yes, please note below:
Name Relationship Age May We Contact? Aware of HIV Status?
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Does the client have dependent children? Yes No
If yes, complete the following:
Name DOB HIV Name of Contact Person Phone Number Aware of HIV
Status School/Daycare Status?
Yes No
Yes No
Yes No
Transportation:
Does client have access to transportation? Yes No
If no, please describe client’s ability to access transportation:
Insurance:
Medicare: Yes No Medicare #: Effective Date: A B D
MEDICAID: Yes No MEDICAID #: Effective Date:
Expiration Date: Date applied if pending:
VA Benefits: Yes No Effective Date: Expiration Date:
Date applied if pending:
ADAP: Yes No Effective Date: Expiration Date:
Date applied if pending:
COBRA coverage: Yes No Name of Ins. Co.:
Group # Subscriber #: Effective Date:
Expiration Date: Date applied if pending: Employer:
Private Insurance: Yes No Name of Ins. Co.:
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Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Group # Subscriber #: Effective Date:
Expiration Date: Date applied if pending:
Employer: Occupation:
Other coverage: Yes No Name of Ins. Co.:
Group # Subscriber #: Effective Date:
Expiration Date: Date applied if pending:
Employer: Occupation:
Financial Resources:
Household Income per month (includes income of client and other household members)
Income Expenses
Client Income Source Status Amount Source Amount
(please check one)
Employment (yes no pending ) Rent/Mortgage
SSD (yes no pending ) Car Payment
SSI (yes no pending ) Transportation
Food Stamps (yes no pending ) Credit Card/Loans
TANF (yes no pending ) Health Care
Unemployment (yes no pending ) Insurance
VA Benefits (yes no pending ) Utilities
Other (yes no pending ) Phone
Total Food
Child Support
Assets Alimony
Source Amount Entertainment
Life Insurance Other
Checking Total Monthly Expenses
Savings Total Monthly Income
Property - Total Monthly Expenses
Burial Insurance Total Monthly Cash Flow
Total Confirmed Zero Income Yes No
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Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Legal Issues:
Legal Documents Status: Please check as appropriate.
DOCUMENT NEEDED NOT INTERESTED COMPLETED
Will
Durable Power of Attorney
Living Will
Health Care Power of Attorney
Guardianship
Burial Plans
Other:
Legal Problems Status: Please indicate information as appropriate.
CHARGES APPROXIMATE DATE LOCATION DISPOSITION
(state, county)
Health:
Primary Care Physician: Phone Number:
Infectious Disease Physician: Phone Number:
Medical Facility most often used: Contact: Phone Number:
Are there any known allergies (drugs, food, and animals, other)? Yes No
Please list known allergies
Does the client have any diagnosed health problems (heart disease, TB, hepatitis, other)? Yes No
Diagnosed Health Problems Treatments Date of Treatment
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Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Has the client ever been hospitalized? Yes No
If yes, please complete the following:
Date Hospital Length of Stay Reason
Dental:
Does the client receive dental care? Yes No
If yes name of dentist:
Phone number:
Does the client have mouth/dental problems that affect what or how much she/he can eat: Yes No
If yes, please describe:
Is there a history of opportunistic infections? Please check yes or no)
History Date
OI Yes No
PCP Yes No
CMV Retinitis Yes No
Histoplasmosis Yes No
Cryptosporidium Yes No
Kaposis Sarcoma Yes No
Shingles Yes No
Toxoplasmosis Yes No
Coccidiomycosis Yes No
Crytococcal Meningitis Yes No
TB Yes No
Invasive Cervical Cancer Yes No Other?
On PCP prophylaxis? Yes No
Is there a history of other HIV related conditions? (Please check yes or no)
Fevers Yes No Virginities Yes No
Night Sweats Yes No PID Yes No
Chills Yes No Thrush Yes No
Fatigue Yes No Dysphagia Yes No
Malaise Yes No Cold Sores Yes No
Weight Loss >10 lbs Yes No Seizures Yes No
Loss of Appetite Yes No Change in Vision Yes No
Diarrhea > 1wk Yes No Periodontal Disease Yes No
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Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Herpes Yes No Short Term Memory Loss Yes No
Syphilis Yes No Hepatitis Yes No
If yes: please comment on these illnesses or others:
Describe any other health concerns not identified above:
Does the client have any visual or hearing impairment?
What affect does the client feel his/her health status has on their ability to work?
What does the client identify as the greatest barriers to keeping medical appointments?
How frequently does the client miss or reschedule medical appointments?
**Current Medications: Please complete the Medical Review and Medications List as part of this
assessment/reassessment. Include HIV, Non-HIV, Psychotropic Medications, OTC Medications, Herbal
Remedies, etc, on the list. Include the most current CD 4 and Viral Load data available.
If taking medications how does the client feel after taking medications?
Name of pharmacy/service and contact number (if applicable):
What barriers does the client identify to taking medications as prescribed?
Identify any past and/or current self-treatments, alternative therapies, etc., and its importance to the client.
How does the client rate his/her overall health? excellent good fair poor
How many meals does the client eat each day? 0-1 2-3 4-5 6+
Does the client seem to have a well balanced diet (fruits, vegetables, grains, proteins and dairy)? Yes No
Please make any other comments you feel necessary to describe nutritional needs:
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Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
ADL’s/IADLs:
Describe client’s ability to function independently in the following areas.
Activity of Daily Living Does Client Need Type of Assistance Source of Assistance
Assistance? Needed
Ability to Ambulate Yes No
Ability to Transfer Self Yes No
Ability to Feed Self Yes No
Ability to Toilet Yes No
Ability to Bathe Self Yes No
Ability to Groom Self Yes No
Ability to Dress Self Yes No
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Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Instrumental Activity of Does the Client Need Type of assistance Source of assistance
Daily Living Assistance? needed: received:
Housecleaning Yes No
Laundry Yes No
Shopping Yes No
Medication Management Yes No
Money Management Yes No
Ability to use phone Yes No
Others?
Others?
Recreation/Leisure:
What does the Client do for fun or stress relief?
Spirituality:
How does Religion play a role in the Client’s life?
What gives the client’s life purpose or meaning? What gives the client hope?
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Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Are there any rituals or beliefs that may impact your healthcare? Yes No
If yes, please describe:
Substance Use:
Identify current or past use of any substances including alcohol, tobacco, prescription and OTC medications:
Frequency of Average Date of last Does client identify
Substance use over past 30 quantity of use use as a problem
days use/day
Yes No
Yes No
Yes No
Yes No
Is the client willing to receive a referral to a substance use counselor? Yes No
If no explain:
Risk:
Substance Abuse Exposed in healthcare Risk Reduction Counseling
Mental Illness Setting Received Yes No
Bisexual Contact Homosexual contact
Heterosexual Contact Perinatal Transmission
Blood Product Recipient Other/undetermined
Sexual partner of prisoner
What is the client’s understanding and use of safer practices to avoid transmission of or re-infection with HIV?
What are the barriers to the client using safer practices?
Does the client believe s/he may currently have a STD?
Does the client need referral for STD testing and/or treatment? Yes No
Does the client need safer sex and/or drug use education? Yes No
Has client notified past/current partners of HIV status? Yes No
If no, describe what steps you took to assist client in this process (such as referral to DIS/Health Department).
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Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Please make any other comments you feel may impact client’s efforts at risk reduction:
Describe your sleep pattern. (Do you wake up in the middle of the night? Do you wake up early? Do you have
trouble falling asleep?). Is this a “regular pattern” for you? Do you feel rested upon waking?
Mental Health:
Is client’s grooming/appearance appropriate? Yes No Is client oriented x3? Yes No
Motor coordination: good fair poor
Thought content: Clear Impaired If impaired describe
Memory: Impaired Unimpaired If impaired describe
Judgment: Impaired Unimpaired Insight: Impaired Somewhat Impaired Intact.
Appears to be under the influence of a substance? Yes No
Do you have any psychiatric history/diagnosis? Yes No If yes, explain
Have you had a significant period (that was not a direct result of drug/alcohol use) in which you have?
Past 30 days Lifetime Comments
Experienced serious depression
Experienced serious anxiety or tension
Experienced hallucinations
Experienced trouble understanding, concentrating
or remembering
Experienced trouble controlling anger that led to
physical violence
Experienced serious thoughts of suicide
Attempted suicide
Been prescribed medication for any
psychological/emotional problem
Wanted to hurt or harm yourself (including self-
mutilation)
Seriously wanted to hurt or harm someone else
Are there any life crises affecting you now? Yes No Please describe
Would you like to talk to someone about your feelings? Yes No
Are you interested in counseling/therapy/support group? Yes No
Have you ever received mental health or counseling services? Yes No If yes, name of provider
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Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Diagnosis?
Are you currently receiving mental health? Yes No If yes, name of provider
Diagnosis?
Have you ever been hospitalized for mental health? Yes No
If yes, please provide:
Date Where Hospitalized Reason Duration
Are you taking medications for mental illness now or have you taken any medication in the past? Yes No
Domestic Violence:
Have you ever been a victim of domestic violence (verbal, mental or physical) Yes No
Are you currently involved in an abusive relationship? Yes No
Community Resources and Support:
Does client’s have knowledge/understanding of available community resources? Yes No
Is the client currently receiving services? Yes No
If yes, please list below:
Agency Contact Name Contact Number Services Received
Client’s primary source of emotional social support:
Name: Address:
Phone:
Comments:
Service Needs Receives Service Needs Receives
AIDS Clinical Trials Advanced Directives
Budget Counseling Burial Assistance
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Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
Case Management Care Teams
Clothing Dental Care
Continuing education Drug/Alcohol Treatment
Domestic Violence Food Assistance
Emergency Shelter Food Stamps
Employment Legal Assistance
HIV Education Medical- HIV Specialty Care
Home delivered Meals Nutritional Counseling
Hospice Services Pharmacy Assistance
Information and Referral Post Test Counseling
Mental Health- Outpatient Risk Reduction Counseling
Nutrition Supplements Spiritual Support
Medicaid SSI/SSDI
Medical-Primary Care Support Groups
Medicare Treatment Adherence
Partner Notification
Referrals to be made:
Summary:
Summarize information gathered from Assessment in a concise coherent manner. Essentially you are identifying
problems and concerns that became evident during your assessment. Please also include strengths, weaknesses that you
have identified in the client.
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Name:
URN#:
DOB:
Sex:
CHARLOTTE TGA
I, ______________________________, certify that all the information I have given is true and accurate to the best of
my knowledge and belief. I agree to provide financial and other verification that may be needed to receive services.
Client (guardian) Signature_____________________________________________Date:_____________________
*Witness Signature (if needed):_________________________________________ Date: ______________________
Case Manager Signature_______________________________________________Date:_____________________
*If you do not have a third party witness available, to witness marks, please write a note of explanation and get your
supervisor to initial and date this form.
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