Clinical Guide > Testing and Assessment > Initial History

# Initial History

January 2011

### Chapter Contents

      - Background
      - S: SubjectiveO: ObjectiveA/P: Assessment and PlanReferencesInitial HistoryReview of SystemsHRSA HAB Core Clinical Performance MeasuresBackground
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 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: SubjectiveInitial HistoryCategory /Topics to CoverSample QuestionsHistory of Present IllnessHIV 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?
- Have you participated in any research protocols?
- What studies, and when? 
- Would you be interested in participating in research studies (if available)?
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 ARVs?
Past Medical and Surgical HistoryChronic DiseasesDo 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 InfectionsHave you ever had any of the following infections? - Syphilis
- Vaginitis
- Genital herpes
- Nongonococcal urethritis (NGU)
- Gonorrhea
- Chlamydia
- Genital warts (HPV)
- Proctitis
- Pelvic inflammatory disease (PID)
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?
ImmunizationsWhen was your last vaccination for the following: - Streptococcal pneumonia (Pneumovax)
- Tetanus/Pertussis (Tdap)
- Influenza
- H1N1
- 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?
- Have you ever had a problem fulfilling work, social, or school obligations because of alcohol use?
**Drug use:**- Do you use any street drugs we haven't covered in earlier questions, or drugs 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 your 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?
**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 QuestionsGender 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?
Sexual Practices - Do you have anal sex? Vaginal? Oral?
- How do you protect yourself from sexually transmitted infections, 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)?
- How do you protect your partners from HIV?
- 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 HistoryRelationship Situation- What is your relationship status (single, married, partnered, divorced, widowed)?
- Do you have children?
Living Situation- Do you live alone or with others? With whom?
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 HealthCoping- 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?
Review of SystemsFor each positive answer, ask about location, characteristics, duration of symptoms, exacerbating and alleviating factors, previous diagnostic workup, and treatments tried.General- Do you ever wake up feeling tired?
Fever- Do you have fevers? How high, and for how long? How often?
Night Sweats- Do you ever sweat so much at night that it soaks your sheets and nightclothes?
Anorexia- How is your appetite?
Weight- What was your weight 1 year ago?
- What is a normal weight for you?
- Have you lost or gained weight unintentionally?
Body Changes- Have you noticed any changes in the shape of your body (describe)? For example, has there been an increase in your waist, collar, or breast size or a decrease in your arm, leg, or buttocks size?
- Have you noticed increased visibility of veins in your arms and legs?
- Have you noticed thinning of your face, especially around the cheeks?
Head, Ears, Eyes, Nose, and ThroatVision- Have you noticed any changes in your vision, especially blurred vision or vision loss, double vision, new "floaters" or flashes of light?
- Have you noticed this problem in one or both eyes?
- When did you first notice these changes?
Mouth, Ears, Nose, Throat- Have you noticed any white spots in your mouth or a white coating on your tongue (thrush, oral hairy leukoplakia)?
- Do you ever get sores in your mouth or the back of your throat? Gum problems?
- Any nosebleeds?
- Do you ever experience hearing loss, ringing in your ears, or ear pain?
CardiovascularCardiac- Any chest pain or pressure? Palpitations?
- Any shortness of breath during activities or while you are lying down?
- How far can you walk or run before you get short of breath?
- Any swelling in your feet or legs?
PulmonaryCough- Do you have a cough?
- Can you describe it? Dry or productive, amount, color, odor, presence of blood in sputum? When is it the worst?
Dyspnea- Do you ever feel short of breath?
- Does that happen when you are sitting still, lying down, or moving around?
- How severe is your shortness of breath?
- What does it prevent you from doing?
- Do you ever wheeze?
GastrointestinalDysphagia- Do you have any problems with food sticking in your throat or being difficult to swallow?
- Do you gag or get nauseated when trying to eat?
- Do you notice it is easier to swallow liquids or solids?
- Do you have difficulty swallowing pills?
Odynophagia- Do you have pain in your throat, esophagus, or behind your breastbone when you swallow?
Dyspepsia/Reflux- Do you ever have heartburn (or a burning feeling rising from the stomach to behind the breastbone)?
- When does it happen -- after eating, lying down, on an empty stomach?
- Do you get the taste of stomach acid in your mouth?
Nausea/Vomiting- Do you have nausea or vomiting?
- When? Are there specific things that cause this?
Diarrhea- Do you have diarrhea, or more than 3-5 unformed stools a day?
- Stool characteristics: bloody, pus, mucus?
- Pain or cramping with diarrhea? Tenesmus?
Bowel Habits- How frequently do you have bowel movements?
- Do you have problems with constipation, blood in the stools, or other?
- Do you have problems with flatulence or belching after eating?
GenitourinaryGenital- Do you have any lesions or sores on your genital area now, or have you in the past?
- Have you ever had genital herpes? If yes, how often do you have outbreaks?
- When was the most recent outbreak?
Women- Have you had any lower abdominal pain?
- Have you noticed a vaginal discharge or odor?
- Do you have any burning or pain on urination?
- Frequent urination?
- Do you lose control of your urine or have problems getting to the bathroom before you start to urinate?
Men- Have you noticed any swelling or testicular pain?
- Do you have difficulty starting your stream of urine?
- Are you getting up at night to urinate?
- Have you had burning or pain on urination?
- Do you lose control of your urine or have problems getting to the bathroom before you start to urinate?
- Do you have any difficulty developing or maintaining an erection?
- Any discharge from your penis?
Musculoskeletal- Do you have any muscle aches or pains? Joint pain or swelling?
- Back pain?
- Have you ever broken any bones?
- Do you have chronic pain?
- Describe the pain -- location, duration, rating (scale of 1-10), alleviating factors.
SkinSkin Lesions- Have you noticed any rash or skin problems? If so, where?
- Have you noticed any new moles, bruises, or bumps on your skin?
- Do you have any moles that have changed shape, size, or color?
Tinea- Do you have fungal infections on your skin, especially groin, fingernails, toenails, or feet?
Folliculitis- Do you have any itchy bumps on your face, back, or chest?
Seborrhea- Do you have flaking or itching on your skin or scalp?
NeurologicHeadache- How often do you get headaches?
- Describe the headaches -- location, timing, duration, alleviating or aggravating factors.
- Do they cause nausea or vomiting?
- Does sensitivity to light lead to headaches?
Neuropathy- Do you have any numbness, tingling, burning, or pain in your hands or feet?
Weakness- Do you have or have you had any weakness in your arms or legs?
Gait- Have you noticed any changes in the way you walk?
Memory- Do you have difficulty with your memory or ability to concentrate? If so, describe. 
Seizures- Have you ever had a seizure or "fit"?
- If so, describe the seizure -- When? How long did it last? Did you experience loss of consciousness? Did you receive medical care?
EndocrineDiabetes- Have you had any increase in thirst, hunger, or urination?
Thyroid- Have you noticed changes in your energy level?
- Do you have intolerance to heat or cold?
- Have you noticed changes in your hair (thinning, coarse texture)?
Sex Steroids- Have you noticed any changes in your libido? In your energy level, mood?
Hematologic/LymphaticAdenopathy- Do you have swollen glands?
- If so, describe -- location, pain, size.
Bruising or Bleeding- Have you noticed easy bruising or prolonged bleeding after injury?
- Nosebleeds or bleeding gums?
PsychiatricMood- Depression screening: Have you experienced a decrease in your interest or pleasure in your activities? Have you felt depressed, down, or hopeless?
- Do you feel more angry, sad, depressed, numb, irritable, or anxious than usual?
- Have any major life events have occurred to cause you to feel sad or depressed?
- When did these events occur?
Sleep- How is your sleep?
- How many hours do you sleep each night?
- What is your sleeping schedule -- time to bed and time to rise?
- Do you take naps?
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, community and other resources, or other clinic services as needed.

During the current visit or a future visit:
- Perform tuberculosis testing (TST or IGRA) if not done in the past year or if the previous result was negative. The patient will need to return to have the TST read. See chapter  Latent Tuberculosis Infection .
- Perform immunizations for pneumonia (Pneumovax), influenza (as appropriate), and other immunizations as indicated. (See chapter  Immunizations for HIV-Infected Adults and Adolescents .)
- Provide counseling on prevention of HIV transmission (e.g., safer sex and injection practices), as appropriate. See chapter  Preventing HIV Transmission/Prevention with Positives .
References- Aberg JA, Kaplan JE, Libman H, et al.; HIV Medicine Association of the Infectious Diseases Society of America.  Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2009 update by the HIV medicine Association of the Infectious Diseases Society of America . Clin Infect Dis. 2009 Sep 1;49(5):651-81.
- Hollander H.  Initiating Routine Care for the HIV-Infected Adult . In: Sande MA, Volberding PA, eds. The Medical Management of AIDS, 5th Edition. Philadelphia: WB Saunders; 1997:107-112.
- Kaplan JE, Benson C, Holmes KH, et al; Centers for Disease Control and Prevention (CDC); National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America.  Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America . MMWR Recomm Rep. 2009 Apr 10;58(RR-4):1-207.
- U.S. Department of Health and Human Services.  Guide to Clinical Preventive Services, 2009: Recommendations of the U.S. Preventive Services Task Force .
- U.S. Department of Health and Human Services.  Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents . January 10, 2011. 
**HRSA HAB Core Clinical Performance MeasuresPercentage of clients with HIV infection who had **two or more medical visits in an HIV care setting** in the measurement year (Group 1) Percentage of clients with HIV infection who received **HIV risk counseling** within the measurement year (Group 2) Percentage of new clients with HIV infection who have been **screened for substance use** (alcohol and drugs) in the measurement year (Group 3) Percentage of new clients with HIV infection who have had a **mental health screening** (Group 3)**