Initial History

Background

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, comorbid conditions, 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 of 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 prevention services and supportive care.

This chapter includes essential topics to cover during the clinic intake and examples of questions that can be used to elicit important information (the questions should be tailored to the individual patient). This can be completed during the initial visit or divided over the course of two or three early visits. For essential aspects of the physical examination to cover in an initial clinic intake visit, see chapter Initial Physical Examination.

S: Subjective

Initial History
Category / Topics to CoverSample Questions
History of Present Illness
HIV Testing
  • What was the date of your first positive HIV test?
  • Did you have a previous HIV test? If so, when was the last negative result?
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?
  • What is your current CD4 (T-cell) count?
  • Do you know what your first CD4 count was?
  • What was your lowest CD4 count?
  • What was your highest CD4 count?
  • Do you know what your first viral load count was?
  • What is your current viral load count?
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 these infections?
  • Have you had cancer(s)?
  • What other HIV-related illnesses have you had? Have you had zoster (shingles), oral thrush, pneumonia?
Active TB and TB Testing History
  • Have you ever had tuberculosis (TB)?
  • When was your last TB test?
  • Was it a TB skin test (TST) or interferon-gamma release assay (IGRA)?
  • What were the results of this test?
  • Have you ever had a positive TB result?
  • What year and what health care setting?
  • What medications did you take and for how long?
Antiretroviral Therapy (ART) History
  • Are you taking HIV medications now?
  • If so, please name them or describe them, and tell me how many times a day you take them.
  • How many doses have you missed in the past 3 days?
  • The past week?
  • The past month?
  • What side effects, if any, do you have now? In the past?
  • What HIV medicines have you taken in the past (names or descriptions)?
  • When did you start and stop taking them (dates)?
  • Do you know why you stopped taking 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?
  • Did you have any side effects to past HIV medications?
Past Medical and Surgical History
Chronic Diseases

Do you have any chronic conditions, such as the following?

  • Diabetes
  • High blood pressure
  • Heart disease
  • Cholesterol problems
  • Asthma or emphysema
  • Sickle cell disease
  • Ulcers, acid reflux, or irritable bowel syndrome
  • Thyroid disorders
  • Kidney or liver problems
  • Mental health disorders

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 whether you are immune to hepatitis A or hepatitis B?
    Have you been vaccinated?
Gynecologic and Women's Health
  • When was your last cervical Papanicolaou (Pap) test?
  • What were the results?
  • Have you ever had an abnormal Pap test?
  • When was your last menstrual period?
  • What is the usual length of your cycle? Is it regular or irregular?
  • Have you noticed changes in your menstrual cycle?
  • When was your most recent breast examination?
  • Have you had a mammogram? When?
  • Have you ever had an abnormal breast examination or mammogram?
  • 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 live births? Ages of children now?
  • How many miscarriages or therapeutic abortions?
  • Were you tested for HIV during any pregnancy? What year?
  • Did you deliver an infant while you were HIV infected?
  • Was HIV medication given during pregnancy and delivery?
  • Do you have children? What is their HIV status?
  • Do you intend to become pregnant?
Anorectal History
  • Have you ever had an anal Pap test?
  • What were the results?
  • Have you had anal warts? Other abnormalities?
Urologic History

Have you ever had:

  • Kidney stones
  • Urinary tract Infections
  • Prostate infection or enlargement
  • Have you had a prostate-specific antigen (PSA) test? (What were the results?)
Sexually Transmitted Diseases

Have you ever had any of the following infections? If yes, when was last episode?

  • Syphilis (If yes, ask about stage, treatment and date of treatment, titer follow-up, and date and result of last titer.)
  • Vaginitis
  • Genital herpes
  • Nongonococcal urethritis (NGU)
  • Gonorrhea (If yes, ask about sites of infection: oral, anal, urethral, vaginal.)
  • Chlamydia (If yes, ask about sites of infection: oral, anal, urethral, vaginal.)
  • Genital warts (HPV)
  • Proctitis
  • Pelvic inflammatory disease (PID)
  • Trichomoniasis
Dental/Oral Care
  • When was your last oral health examination?
  • Do you have all your natural teeth?
  • Do you have partials or dentures?
Eye Care
  • When was your last vision examination?
  • When was your last dilated retinal examination?
  • Do you wear glasses or corrective lenses?
Medications
  • What (non-ARV) medications do you take?
  • What herbs, vitamins, nutritional supplements, or over-the-counter (OTC) medications, do you take?
Allergies; Medication Intolerance
  • Have you had an allergic reaction to any medications? What type of reaction, how severe?
  • Have you had allergic reactions to other types of exposures?
  • Have you had severe side effects from any medications?
Immunizations

When was your last vaccination for the following:

  • Streptococcal pneumonia (Pneumovax; PPV23, PCV13)
  • Tetanus/Pertussis (Tdap)
  • Influenza
  • Hepatitis A
  • Hepatitis B

Did you have chickenpox as a child, or were you vaccinated against chickenpox?

What about measles, mumps, and rubella?

Health-Related Behaviors

Tobacco use:

  • Do you smoke? How many cigarettes per day? How long have you smoked? How much have you have smoked in the past?
  • Besides tobacco, what do you smoke?
  • Do you chew tobacco?

Alcohol use:

  • How often do you have a drink containing alcohol? How many drinks do you have on a typical day? How many per week?
  • Have you ever had a problem fulfilling work, social, or school obligations because of alcohol use?
  • Have you ever sought treatment for alcohol-related problems?

Drug use:

  • Do you use any recreational or street drugs we haven't covered in earlier questions? Any prescription drugs or medications that were not prescribed to you?
  • If so, what drugs and how do you use them (inject, smoke, inhale, etc.)?
  • How often do you use substances?
  • Have you shared drug-use equipment with another person?
  • What pain relievers do you use on a regular basis?
  • Are you interested in treatment for alcohol or drug use?
  • Have you ever sought treatment?

Exercise:

  • What kind of exercise do you participate in? How frequently?

Diet:

  • What do 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 a typical day?
  • What is your source of water?
  • How much caffeine do you drink during a typical day?
Sensitive Sexual and Gender History Questions
Gender Identity
  • Do you consider yourself male or female?
  • Have you had or considered treatment for sex change?
  • Are you presently taking hormone therapy?
  • Have you had hormone therapy in the past?
  • Have you had any gender confirmation (sex reassignment) surgery?
General Sexual
  • Do you have sex with men, women, or both?
  • In the past, have you had sex with men, women, or both?
  • In the past 2 months, how many sex partners have you had?
  • In the past 12 months, how many sex partners have you had?
Sexual Practices
  • Do you have anal sex? Vaginal? Oral?
  • How do you protect yourself from sexually transmitted diseases, or HIV reinfection?
  • 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?
HIV Prevention
  • Do you know the HIV status of your partner(s)?
  • Do you take measures to protect your partners from HIV? What measures?
  • In what situations do you or your partner use condoms or some other barrier?
  • Are there situations in which you do not use barrier protection?
Sex Trading
  • Have you ever exchanged sex for food, shelter, drugs, or money?
Contraception
  • What birth control measures do you use, if any?
  • How often do you use condoms or other latex barriers?
  • Do you have plans for you or your partner to become pregnant?
Family History
 

Do you have a family history of:

  • Heart disease? Heart attacks or strokes?
  • Cholesterol problems? Diabetes?
  • Cancer?
  • Mental health conditions (e.g., depression, bipolar disorder, anxiety, 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)?
  • Do you have children?
  • Does your partner (and/or children) know about your HIV status?
Living Situation
  • Do you live alone or with others? With whom?
  • How long have you lived in your residence?
Support System
  • Who knows about your HIV status?
  • Which individual has been the most supportive since your HIV diagnosis?
  • Who has been the least supportive?
  • Have you used any community 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?
  • Does your employer know of your HIV status?
  • If on disability: How long have you been on disability?
  • What medical condition has made you disabled?
Incarceration History
  • Have you ever been incarcerated? When was the last time?
Pets
  • What kind of pets do you have, and who cleans up after them?
Travel
  • Where have you traveled outside the United States?
  • When did travel take place?
Mental Health
Coping
  • How do you handle your problems/stresses?
  • What do you do to relax?
History
  • Have ever been diagnosed with depression, anxiety, panic, bipolar disorder, schizophrenia, 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 Suicide Risk and prepare for immediate referral if necessary.)
Violence
  • Have you ever been sexually abused, assaulted, or raped?
  • Has an intimate partner ever forced you to do something you did not want to do?
  • Has a partner, family member, or other person ever physically hurt you?
  • Have you lived in any situation with physical violence or intimidation?
  • When has this occurred?
  • Are you afraid for your safety now?
  • (If yes) Did you seek legal help, therapy, or other type of assistance?
Childhood Trauma
  • 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?

O: Objective

  • 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 review of symptoms (ROS) and the physical examination, perform another ROS.

A/P: Assessment and Plan

  • Arrange for baseline/intake laboratory work. (See chapter Initial and Interim Laboratory and Other Tests.)
  • Compose a problem list. Initiate a medication list (if appropriate).
  • Refer the patient to social services, mental health care, local health department partner services, community and other resources, or other clinic services as needed.

During the current visit or a future visit:

Patient Education

A very important aspect of caring for HIV-infected individuals is educating patients about HIV infection, including goals of care and ways of achieving those goals.

Review the following with each patient:

HIV disease

  • Disease course
  • Significance of CD4 cell count and HIV viral load
  • Possible treatment approaches, including initial discussion about the importance of ART for the patient's own health and for reducing risk of HIV transmission
  • Disclosure (e.g., whom the patient may need to tell about HIV status, relevant legal requirements, approaches to disclosure)

HIV transmission prevention and risk reduction for HIV-infected individuals

(see chapter Preventing HIV Transmission/Prevention with Positives)

  • Strategies to prevent transmission of HIV to uninfected partners and to prevent acquisition of sexually transmitted diseases, hepatitis, and other infections
  • Safer-sex approaches, including the use of condoms or other latex barriers during sexual contacts
  • Safer use of recreational drugs

Nutrition

  • Maintaining a healthy weight
  • Nutritional support resources, if appropriate
  • Importance of including a nutritionist in medical care

Mental health

  • Stress reduction
  • Rest and exercise to enhance a healthy mental state

Adherence

  • Importance of keeping medical appointments
  • Need for adhering to any medication regimen and the consequences of missed HIV medication doses

References

Search the Clinical Guide

Rate This Chapter

HRSA HAB Performance Measures

Abbreviations for Dosing Terminology

BID
twice daily
BIW
twice weekly
IM
intramuscular (injection), intramuscularly
IV
intravenous (injection), intravenously
PO
oral, orally
Q2H, Q4H, etc.
every 2 hours, every 4 hours, etc.
QAM
every morning
QD
once daily
QH
every hour
QHS
every night at bedtime
QID
four times daily
QOD
every other day
QPM
every evening
TID
three times daily
TIW
three times weekly