Apla Diagnosis Form PDF Details

Aplastic anemia is a rare blood disorder in which the body's bone marrow doesn't make enough new blood cells. Affecting both adults and children, aplastic anemia can be caused by toxins, radiation therapy, or inherited disorders. While there is no cure for aplastic anemia, treatments are available to help patients live a normal life. If you or your child has been diagnosed with aplastic anemia, it is important to understand the condition and what treatment options are available. The Apla Diagnosis Form can help you do just that. Created by the Apla Foundation, this form provides information on aplastic anemia symptoms, diagnosis, and treatment options. It also includes contact information for support groups

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

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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

 

 

 

 

 

 

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