Form 1 IntakeAndTarget_20111014

Patient Navigator Outreach and Chronic Disease Prevention Program

Patient Intake Form
Study ID:
Enrollment Date:

Subsite:

Demographics

Household

Gender (Check one) *
 Male
 Female
 Transgender

3-digit zip prefix

Birth year *

__ __ __

Household size
__ __ __ __

Ethnicity (Check one) *
 Hispanic or Latino
 Non-Hispanic
Race (Check all that apply)
 White
 Black/African American
 Asian
 Native Hawaiian/Pacific Islander
 American Indian/Alaska Native
 Refused
Optional race coding:
Primary/preferred language *
(Check one)
 English
 Spanish
 Chinese
 Fijian
Filipino
Tagalog
 French
Ilocano
 Haitian Creole
Visayan
 Hmong
Other
 Japanese
 Korean
Micronesian
Chuukese
 Mixteco
Kosraean
 Navajo
Marshalese
 Samoan
Pohnpeian
 Somali
Yapese
 Tongan
 Vietnamese
 Other
 Specify:

Rev. 19-Sep-2011

Navigated Condition(s)

Refused

Education (Check one)
 No formal education
 Primary education only
 Some HS/secondary education
 HS Diploma/GED/other secondary
education
 Some college/vocational school/
other post-secondary education
 Completed college, post-secondary
or vocational school
 Post-college/graduate school
 Refused

* Required for registration

Local Identifiers (site use only)

Navigator:

__ __
Refused

(# in household, Including patient)

Household income (Check one)
Less than $10K
$10K to $19,999
$20K to $29,999
$30K to $39,999
$40K to $49,999
$50K or more
Refused
Utilization
# Hospital stays, past year
None
One stay
More than 1 stay
Not Available
# ER visits, past year
None
One ER visit
More than 1 visit
Not Available
Coverage

Pharmacy assistance
No
Yes
Not Available
Heath care coverage
(Check all that apply)
No coverage
Medicare
Medicaid
IHS (Indian Health Service)
Private insurance
Other Government plan
Single service plan
Reduced-fee/sliding scale
Free care
Other
 Specify:

Check all that apply

Asthma
__ __ / __ __ / __ __ __ __
Asthma, at risk/pre-asthma
Asthma, diagnosed
CHF
__ __ / __ __ / __ __ __ __
(Congestive Heart Failure)
CHF, diagnosed
CVD
__ __ / __ __ / __ __ __ __
(Cardiovascular Disease)
CVD, at risk/family history
CVD, diagnosed
Depression
__ __ / __ __ / __ __ __ __
Depression, positive screen
Depression, diagnosed
Diabetes
__ __ / __ __ / __ __ __ __
Diabetes, at risk/family history
Diabetes, pre-diabetes
Diabetes, diagnosed
Gestational diabetes
Hyperlipidemia __ __ / __ __ / __ __ __ __
Hyperlipidemia, diagnosed
Hypertension __ __ / __ __ / __ __ __ __
Hypertension, positive screen
Hypertension, diagnosed
Obesity
__ __ / __ __ / __ __ __ __
Obesity (adult)
Obesity (pediatric)
Other
Other
 Specify:

__ __ / __ __ / __ __ __ __

Cancer

__ __ / __ __ / __ __ __ __

Type of cancer:
Cancer, screening
Cancer, abnormal finding
Cancer, diagnosed
 Stage: 0 1 2 3

4

N/A

Entered: __ __ / __ __ / __ __ By: _______

Patient Navigator Outreach and Chronic Disease Prevention Program

Patient Intake Form (cancer only)
Study ID:
Enrollment Date:

Subsite:

Demographics

Household

Gender (Check one) *
 Male
 Female
 Transgender

3-digit zip prefix

Birth year *

__ __ __

Household size
__ __ __ __

Ethnicity (Check one) *
 Hispanic or Latino
 Non-Hispanic
Race (Check all that apply)
 White
 Black/African American
 Asian
 Native Hawaiian/Pacific Islander
 American Indian/Alaska Native
 Refused
Optional race coding:
Primary/preferred language *
(Check one)
 English
 Spanish
 Chinese
 Fijian
Filipino
Tagalog
 French
Ilocano
 Haitian Creole
Visayan
 Hmong
Other
 Japanese
 Korean
Micronesian
Chuukese
 Mixteco
Kosraean
 Navajo
Marshalese
 Samoan
Pohnpeian
 Somali
Yapese
 Tongan
 Vietnamese
 Other
 Specify:

Rev. 14-Oct-2011

Navigated Condition(s)

Refused

Education (Check one)
 No formal education
 Primary education only
 Some HS/secondary education
 HS Diploma/GED/other secondary
education
 Some college/vocational school/
other post-secondary education
 Completed college, post-secondary
or vocational school
 Post-college/graduate school
 Refused

* Required for registration

Local Identifiers (site use only)

Navigator:

__ __

Cancer, screening
Cancer, abnormal finding
Cancer, diagnosed

Refused
(# in household, Including patient)

Household income (Check one)
Less than $10K
$10K to $19,999
$20K to $29,999
$30K to $39,999
$40K to $49,999
$50K or more
Refused
Utilization
# Hospital stays, past year
None
One stay
More than 1 stay
Not Available

Date:

__ __ / __ __ / __ __ __ __

Type of cancer:
Diagnosed cancer only
Stage:

0

1

2

Substage (optional):

3
A

4
B

N/A
C

TNM Staging (optional):
Histology(optional):

# ER visits, past year
None
One ER visit
More than 1 visit
Not Available
Coverage

Pharmacy assistance
No
Yes
Not Available
Heath care coverage
(Check all that apply)
No coverage
Medicare
Medicaid
IHS (Indian Health Service)
Private insurance
Other Government plan
Single service plan
Reduced-fee/sliding scale
Free care
Other
 Specify:
Entered: __ __ / __ __ / __ __ By: _______

Patient Navigator Outreach and Chronic Disease Prevention Program

Navigation Target Form

Type of Service

Study Data

Navigator ID:
Date Identified:

Date Scheduled:

Notes

Medical visit for other conditions
 Lab or diagnostic test
 Primary care
 Medical specialist (MD or DO)
Optional:

Unscheduled Service

Check one

 Internal
 External

Location Notes:

Status Options
Open target:
Scheduled
Rescheduled
Canceled
No show
Paperwork complete

Check one

Medical visit for cancer
 Screening
 Diagnostic test
 Cancer treatment

Study ID:

Location

Local Identifiers (site use only)

Closed target:
Services received
Ineligible
Unable to access
No longer relevant
Refused

Health education
 Certified diabetes educator
 Nutritionist
 Other health education/disease
management
Social services and assistance
 Health care coverage
 Pharmacy assistance
 Medical equipment
 Other service (Government agency)
 Other service (nonprofit/charitable org)
Other services
 Behavioral/mental health services
 Clinical trials
 Other
 Specify:

Use the table below to record scheduling changes and/or target resolution.

Date

Rev. 20-Sep-2011

Status

Notes (optional)

Entered: __ __ / __ __ / __ __ By: _______

Navigation Target Form (page 2)

Use the table below to record scheduling changes and/or target resolution.

Date

Status

Notes (optional)

Notes:

Rev. 20-Sep-2011

Entered: __ __ / __ __ / __ __ By: _______