HIV Initial Intake Note

Date/Time: [Encounter date and time]

Location: [Clinic or site name]

Patient: [Legal name] — [DOB] — [MRN]

Preferred Name/Pronouns: [Preferred name and pronouns] (Only include if different from legal name or explicitly provided.)

Source of History: [Patient / partner / outside records / combination] — [Reliability or limitations noted] (Specify source(s); note reliability concerns when present.)

Referral Context: [New diagnosis / transfer of care / re-engagement after lapse / other linkage pathway]

Chief Concern

[Patient-stated reason for visit] (Limit to 1–2 lines. Include a brief direct quote only when it clarifies urgency or symptom quality.)

History of Present Illness

Current symptoms and OI red flags: [Symptom narrative including onset, duration, severity, and associated features] (Emphasize fever, weight loss, night sweats, cough or dyspnea, headache or altered mental status, diarrhea, oral lesions, rash, visual changes, focal neurologic deficits. Include only positives and pertinent negatives explicitly discussed.)

Care engagement context: [Date and circumstances of HIV diagnosis; prior care sites; treatment gaps; reason for visit today] (If information is not available, state that records are pending and note follow-up action in the plan.)

ART readiness assessment: [Daily medication readiness; housing and food stability; insurance and pharmacy access; mental health or substance use factors affecting adherence] (Document barriers and facilitators to adherence. If unknown, specify what will be clarified and by whom.)

HIV History

Diagnosis and Timeline: [Date of HIV diagnosis; screening versus symptomatic presentation; last known negative test if available; prior care sites; interruptions in care] (Include approximate dates when exact dates are unavailable.)

HIV Disease Markers: Diagnosis date: [date or pending]; Last negative test: [date or unavailable]; Most recent CD4: [value with date or pending]; Most recent HIV RNA: [value with date or pending]; CD4 nadir: [value with date or unavailable]; Prior genotype dates: [dates or unavailable] (State explicitly when values are pending or unavailable. Do not omit this line even if data are pending.)

AIDS-Defining Conditions:

• [Condition with approximate date and treatment] (List PCP, toxoplasmosis, cryptococcosis, MAC, CMV, TB, Kaposi sarcoma, or others as applicable. Do not infer diagnoses without documentation.)
• [Prior OI prophylaxis history and tolerability] (Include agents used and any intolerance.)

Transmission Risk Discussion: [Risk-reduction counseling provided; partner notification needs and assistance offered; counseling on viral suppression and transmission prevention]

ART History and Resistance

Current ART Status: [ART-naive / ART-experienced / restarting after interruption]

Prior regimens:

• [Regimen] — [Approximate dates] — [Virologic outcome] — [Reason for change or discontinuation] (Note adherence patterns and barriers. Include prior long-acting ART exposures if any.)

Resistance history: [Known mutations with genotype dates and source] (If unknown, state "resistance history unknown—records requested.")

Prior PrEP or PEP exposure: [Agents and dates, including any long-acting prevention ARVs]

Resistance testing plan: Baseline genotype: [ordered / not ordered]; Integrase resistance testing: [ordered / not indicated]; ART initiation before results: [yes / no] — [Contingency plan if resistance detected]

Past Medical History

• [Condition]: [Brief status] — [Current therapy or monitoring] (Prioritize cardiovascular risk factors, renal disease, hepatic disease and viral hepatitis status, bone health, psychiatric conditions, substance use disorders with treatment status, pregnancy potential or reproductive goals, and medications with interaction risk.)

Surgical History

• [Procedure and date]

Medications

• Current non-ART medications: [Medication with dose and frequency] (Include OTCs, supplements, herbals.)
• Current ART: [Regimen with dose and frequency] (Omit if ART-naive.)
• Current OI prophylaxis: [Agent, dose, indication] (Omit if none.)
• Recent medications affecting OI risk or ART interactions: [Steroids, chemotherapy, rifamycins, others] (Omit if none.)
• Medication list incomplete — pharmacy verification requested from [pharmacy names] (Only include if list is incomplete.)

Allergies

• [Substance] — [Reaction type] — [Severity] — [Timing or context] (Differentiate hypersensitivity from intolerance. Note relevance for sulfa drugs and abacavir considerations.)

Family History

• [Premature cardiovascular disease, diabetes, cancers relevant to screening with ages of onset when available]

Social History

Social determinants: [Housing stability; food security; transportation access; employment and income; insurance status] (Use nonjudgmental, patient-centered language.)

Support and safety: [Support system; disclosed stigma or safety concerns; incarceration or congregate living if relevant to care; intimate partner violence screening result when indicated]

Substance use: [Tobacco and vaping status; alcohol quantity and frequency; drug use including route and injection practices; needle sharing history; harm reduction practices; prior treatment; interest in treatment; overdose history; naloxone access]

Sexual Health History

[Number and gender of partners; sexual practices including oral, vaginal, anal with receptive or insertive roles; protection methods; past STI history; pregnancy intention if applicable; anatomic sites relevant to screening] (Document respectfully. This section directly informs STI testing sites, vaccination needs, partner services, and eligibility for doxycycline post-exposure prophylaxis.)

Immunizations

[Documented vaccines with dates] (If incomplete, state "immunization history incomplete—registry requested.")

• Vaccines due at this visit: [List]
• Vaccines deferred: [List] — [Rationale] (e.g., live vaccine contraindication with low CD4)
• Serology-linked vaccines: [Hepatitis B, hepatitis A, MMR, varicella serologies linked to vaccine plan]

Screening and Preventive Care Status

• STI screening by site: Urogenital: [done / ordered / deferred / not indicated]; Pharyngeal: [status]; Rectal: [status]; Syphilis serology: [status]
• TB screening: [TST / IGRA] — [done / ordered / deferred / not indicated] — [Rationale if deferred]
• Viral hepatitis: HBV panel: [status]; HCV antibody with reflex RNA: [status]
• Cervical cancer screening: [status] (If cervix present.)
• Anal cancer screening: [status] — [Approach per local protocol]
• Age-appropriate cancer screening: Breast: [status]; Colon: [status]; Lung: [status if indicated]
• Metabolic screening: Lipids: [status]; Glucose/A1c: [status]; Blood pressure: [status]

Review of Systems

(Focused to HIV-relevant systems. Document pertinent positives and negatives. Avoid exhaustive negatives unrelated to the presentation.)

• Constitutional: [Fever; weight change; night sweats; fatigue]
• HEENT: [Oral lesions; visual changes; headache]
• Respiratory: [Cough; dyspnea]
• Cardiovascular: [Chest pain; palpitations]
• Gastrointestinal: [Diarrhea; dysphagia; abdominal pain]
• Dermatologic: [Rash; lesions]
• Neurologic: [Weakness; sensory changes; cognitive concerns]
• Psychiatric: [Mood; anxiety; sleep]
• Genitourinary: [Dysuria; discharge; lesions; pelvic or testicular pain]

Vitals

BP: [Value] HR: [Value] RR: [Value] Temp: [Value] SpO2: [Value] Weight: [Value] BMI: [Value] [Significant recent weight change if applicable]

Physical Examination

• General: [Appearance and nutritional status]
• HEENT: [Oral cavity for thrush or lesions; other pertinent findings]
• Lymph nodes: [Cervical, axillary, inguinal findings]
• Skin: [Rash or lesions]
• Lungs: [Auscultation findings]
• Cardiac: [Rate, rhythm, murmurs]
• Abdomen: [Tenderness; hepatosplenomegaly; other findings]
• Neurologic: [Mental status; focal deficits]
• Genital, rectal, pelvic: [Findings if examined] (Document patient consent and chaperone when applicable. Omit section if not examined.)

Data Review

Outside Records Reviewed: [Source and date range] — [Key extracted information including prior HIV markers, genotypes, OI history, immunizations] (Omit if no outside records reviewed.)

Baseline Labs Available Today: [List specific results with dates] (For CD4, HIV RNA, hepatitis serologies, and renal function, include numeric values rather than "normal" or "WNL." If none available, state "no prior laboratory data available.")

Orders Placed Today:

• HIV staging: CD4: [ordered / pending]; HIV RNA: [ordered / pending]; Genotype: [ordered / pending]; Integrase resistance: [ordered / pending / not indicated]
• Safety labs: CMP: [status]; CBC: [status]; Urinalysis: [status]
• Coinfection screening: HBV panel: [status]; HCV antibody with reflex: [status]; TB test: [status]
• STI screening: Syphilis serology: [status]; Gonorrhea/chlamydia by site: [status]
• Pregnancy test: [status] (Include only if indicated.)
• Immunization serologies: [Hepatitis B surface antibody; varicella; MMR as applicable]: [status]

Assessment and Plan

Problem 1: HIV Infection

Assessment: [HIV stage based on available markers with dates or pending status; ART status; key constraints including coinfections, pregnancy potential, renal function, drug interactions; resistance testing status]

• ART plan: [Initiate / continue / restart] [Regimen name] — [Rationale including HBV coverage, pending genotype, renal dosing] (Document if starting ART prior to resistance results and contingency plan.)
• Adherence support: [Counseling provided; identified barriers; solutions and supports]
• Drug interaction review: [Completed; issues addressed]
• Pharmacy linkage: [Pharmacy selected; benefits assistance; prior authorization plans]
• Monitoring: [Timing for repeat HIV RNA and CD4; safety labs schedule]
• Results communication: [Method and timing for follow-up of results]
• Transmission risk counseling: [Actions and resources provided; partner notification support]

Problem 2: OI Prophylaxis

Assessment: [Current indications based on CD4 or pending CD4; history of prior OIs relevant to secondary prophylaxis]

• Plan: [Prophylaxis initiated: agent, dose, indication] OR [Deferral rationale] (If CD4 is pending, include conditional plan such as "initiate PCP prophylaxis if CD4 less than 200 when resulted." Note G6PD testing if dapsone is being considered.)

Problem 3: Coinfections

• TB: [Screening test ordered or result] — [Plan for latent TB treatment if positive after excluding active disease]
• Hepatitis B: [Serology interpretation: immune / susceptible / chronic infection / occult] — [Vaccination series, treatment considerations, ART selection for HBV coverage]
• Hepatitis C: [Screening result or ordered] — [Referral pathway if positive]

Problem 4: Sexual Health and STI Screening

• STI testing by site: [Sites ordered and rationale based on sexual health history]
• Syphilis: [Testing and treatment plan including any empiric treatment if indicated]
• Doxycycline post-exposure prophylaxis: [Eligibility assessment and shared decision-making] (Include for MSM or transgender women with bacterial STI in past 12 months.)
• Contraception and pregnancy planning: [Counseling and plan] (Include when relevant.)

Problem 5: Immunizations

• Vaccines administered today: [List]
• Vaccines deferred: [List and rationale]
• Series completion plan: [Schedule and any needed titer rechecks]

Additional Problems

• [Problem]: [Brief assessment] — [Plan including orders, referrals, and counseling] (Prioritize immediate needs versus items to address at subsequent visits. Add additional problem headings as needed.)

Orders and Referrals Summary

• Labs: [List] — [ordered / completed / pending]
• Imaging: [List] — [status] (Omit if none.)
• Medications prescribed: [List with doses]
• Vaccines administered: [List]
• Referrals: [List] — [status]

Follow-Up and Care Coordination

• Follow-up appointment: [Timing and rationale] (Use rapid follow-up if ART is started before all results return.)
• Care coordination services: [Case management; benefits navigation; Ryan White enrollment; pharmacy assistance; mental health referral; substance use treatment referral; other supports as indicated]