APLA Diagnosis Form PDF Details

The APLA Diagnosis Form is a structured reporting tool designed for licensed, practicing physicians in Los Angeles County. Completed forms allow AIDS Project Los Angeles (APLA) to provide coordinated care and targeted support to individuals living with HIV or AIDS.

The form records patient identification details alongside critical diagnostic information: the date of HIV or AIDS diagnosis, current symptoms, opportunistic infections, and key laboratory data including CD4 cell count and HIV viral load. Physicians also document the Karnofsky Scale Assessment, skilled nursing care requirements, dental health status, and tuberculosis screening results.

Physicians managing patients with related conditions may also need a Negative HIV Test Form to confirm a patient's current status, or an Attending Physician Statement for insurance documentation. California-licensed physicians can also find the California Participating Physician Form in our catalog for provider enrollment purposes.

Fill out as much information as possible on the APLA Diagnosis Form to give AIDS Project Los Angeles a complete picture of each patient's medical needs. Thorough documentation directly supports better care coordination and resource allocation for individuals in the community.

QuestionAnswer
Form NameAPLA Diagnosis Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesapla kingsley medical diagnosis form, apla health forms, apla physician diagnosis form, apla karnosky form

Form Preview Example

PHYSICIAN DIAGNOSIS FORM

PHYSICIANS: A licensed, practicing physician in Los Angeles County should complete as much of this form as possible. If you do not respond to a question, we will assume that you do not have an answer to that particular question. Return to the AIDS Project Los Angeles Registrar by fax at 213.201.1392 or mail to: AIDS Project Los Angeles, The David Geffen Center, 611 South Kingsley Drive, Los Angeles, CA 90005.

Last Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

First Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Middle Name _ _ _ _ _ _ _ _ _ _ _ _ _ _

 

 

 

 

 

 

 

 

 

 

Date of Birth

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Social Security No.

_

 

 

_

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

DIAGNOSIS:

❏ HIV+ Asymptomatic (No Symptoms)

 

 

❏ HIV+ Symptomatic

 

 

(Choose only one)

 

 

 

 

 

❏ AIDS Asymptomatic (No Symptoms)

 

 

❏ AIDS Symptomatic

What was the date of this diagnosis?

 

 

 

Year of first positive test for HIV: ___________

 

 

 

DATE

 

 

 

 

 

Symptoms that substantiate this diagnosis:

❏ Diarrhea

❏ Fevers

❏ Fatigue

Opportunistic infections that substantiate this diagnosis:

❏CD4 < 200/14%

DATE

❏PCP

DATE

❏Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

❏KS

DATE

❏Other

DATE

Current symptoms related to HIV disease or treatment include: ___________________________________________

______________________________________________________________________________________________

LAB DATA:

CD4 cell count _ _ _ _ _ _ _ _ _ _ _ _ _ ;

CD4 percentage _ _ _ _ _ _ _ _ _ _ _ _ _ % as of

 

 

 

 

 

 

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

 

 

 

 

 

 

 

 

 

 

DATE

 

 

HIV viral load

as of

 

 

 

 

 

 

 

 

 

 

 

 

Neutrophil count _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

 

 

 

DATE

 

 

 

 

 

 

 

 

 

cells/mm3 as of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

OTHER ILLNESSES: Is there any other illness we need to be aware of?

❏ Yes

❏ No

If yes, please describe:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

KARNOFSKY SCALE ASSESSMENT:

(Please check the appropriate numerical value)

 

 

❏ 100 =

Stage I

❏

80 =

Stage I

❏

60 =

Stage II

❏

40 =

Stage III

❏

20 =

Stage III

❏ 90 =

Stage I

❏

70 =

Stage II

❏

50 =

Stage II

❏

30 =

Stage III

❏

10 =

Stage IV

SKILLED NURSING CARE:

Does this patient meet the nursing facility level of care?

❏ Yes

❏ No

DENTAL:

Is this patient medically able to receive routine dental care and/or oral procedures?

❏ Yes

❏ No

TUBERCULOSIS:

Has this patient been screened for TB?

❏ Yes

❏ No

 

TB skin test date

 

 

 

 

 

.......................

❏ Positive

❏ Negative

 

TB chest X-ray date

 

 

 

 

.......................

❏ Positive

❏ Negative

 

This patient is currently . . .

❏ Receiving preventative TB treatment

❏ Not receiving treatment

❏ Receiving treatment for active TB

❏ Non-compliant with recommended treatment

 

 

I am the physician responsible for the above patient’s HIV care. I certify that the above information is correct and based on a review of the patient’s HIV treatment needs.

_________________________________________________

 

 

 

 

 

Signature of Physician

 

Date Completed

 

 

_________________________________________________

 

 

 

 

 

Physician’s Name

 

CA License #

 

 

_________________________________________________

(

)

 

 

Address

 

Phone

 

 

_________________________________________________

 

 

 

 

 

City

 

State

Zip Code

3 OF 14

 

 

 

 

 

 

How to Edit Apla Diagnosis Form Online for Free

The APLA Diagnosis Form is a one-page document that licensed physicians complete and submit to AIDS Project Los Angeles. Follow the steps below to fill out the form correctly and ensure it meets APLA reporting requirements.

Step 1: Enter Patient Identification Information

Record the patient's full legal name, date of birth, and address at the top of the form. Include any identification or case numbers assigned by APLA or the treating facility. Accurate identification data is required for APLA to match the form to existing patient records.

Step 2: Document the HIV or AIDS Diagnosis Date

Enter the date of the patient's initial HIV diagnosis and, if applicable, the date the condition progressed to AIDS. These dates anchor the patient's care timeline and help APLA determine eligibility for specific support programs.

Step 3: Record Current Symptoms and Opportunistic Infections

List all current symptoms and active opportunistic infections. Common opportunistic infections documented on this form include Pneumocystis pneumonia, toxoplasmosis, and cytomegalovirus. Complete this section as thoroughly as possible to give APLA a full picture of the patient's health status.

Step 4: Enter Laboratory Values

Record the most recent CD4 cell count and HIV viral load from laboratory tests. These values help APLA determine appropriate care levels and connect the patient with the right support resources. Include the date each test was performed.

Step 5: Complete the Karnofsky Scale Assessment

Use the Karnofsky Performance Scale to rate the patient's functional capability. Scores range from 0 to 100, where higher scores indicate greater independent function. This rating helps APLA assess whether the patient requires skilled nursing care or other intensive support services.

Step 6: Address Additional Care Needs

Complete the sections on skilled nursing care requirements, dental health status, and tuberculosis screening results. If TB screening has not been completed, note this on the form. Each of these fields guides APLA's resource allocation decisions for the individual patient.

Step 7: Sign and Submit the Completed Form

The treating physician must sign and date the completed APLA Diagnosis Form. Submit the signed form directly to AIDS Project Los Angeles for processing. APLA reviews each submission to assign care coordinators and direct appropriate community resources to the patient.

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