(For MCM to answer) Based on the above information, rate the client’s level of HIV knowledge: Excellent Very Good Good Fair Poor How often do you need help reading the following: Written information about how to take care of yourself? Always Sometimes Never Written information about how to take your medications? Always Often Sometimes Never Witten information medication side effects? Always Often Sometimes Never Appointment notifications and reminders? Always Often Sometimes Never Treatment information from your dietician, MCM, or mental Always Often Sometimes Never health/substance abuse counselor? How often do you need help with the following: Figuring out the time to take medications? Always Often Sometimes Never Figuring out if you need to eat with medications? Always Often Sometimes Never Understanding your medical provider when he/she talks Always Often Sometimes Never about your health? Being able to effectively communicate your needs to your Always Often Sometimes Never medical provider? Being able to effectively negotiate your health care? Always Often Sometimes Never Discussing your insurance with your clinic’s billing office? Always Sometimes Never Discussing your benefits with your insurance plan? Always Often Sometimes Never Filling out your medical forms by yourself? Always Often Sometimes Never Comments: Health and Medical Care New Need Continuing Need Since last (re)assessment, there has been: This is a: No changes Changes Not a need If are changes and/or this is a new/continuing need, then updates must be provided below. MEDICAL APPOINTMENTS Yes No Are you in medical care? If yes, complete chart below: CLINIC NAME TYPE OF PROVIDER NAME LAST APPOINTMENT NEXT APPOINTMENT ADDRESS/PHONE Primary Care Kept Missed Rescheduled Infectious Disease Kept Missed Rescheduled Other: Kept Missed Rescheduled Kept Missed Rescheduled How are your appointments with the ID provider? More often than once a month Once every month Once every 2-3 months Once every 6 months Other:
(For MCM to answer) Based on the above information, rate the client’s level of HIV knowledge: Excellent Very Good Good Fair Poor How often do you need help reading the following: Written information about how to take care of yourself? Always Sometimes Never Written information about how to take your medications? Always Often Sometimes Never Witten information medication side effects? Always Often Sometimes Never Appointment notifications and reminders? Always Often Sometimes Never Treatment information from your dietician, MCM, or mental health/substance abuse counselor? Always Often Sometimes Never How often do you need help with the following: Figuring out the time to take medications? Always Often Sometimes Never Figuring out if you need to eat with medications? Always Often Sometimes Never Understanding your medical provider when he/she talks about your health? Always Often Sometimes Never Being able to effectively communicate your needs to your medical provider? Always Often Sometimes Never Being able to effectively negotiate your health care? Always Often Sometimes Never Discussing your insurance with your clinic’s billing office? Always Sometimes Never Discussing your benefits with your insurance plan? Always Often Sometimes Never Filling out your medical forms by yourself? Always Often Sometimes Never Comments: Health and Medical Care Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If are changes and/or this is a new/continuing need, then updates must be provided below. MEDICAL APPOINTMENTS Are you in medical care? Yes No If yes, complete chart below: TYPE OF PROVIDER NAME CLINIC NAME ADDRESS/PHONE LAST APPOINTMENT NEXT APPOINTMENT Primary Care Kept Missed Rescheduled Infectious Disease Kept Missed Rescheduled Other: Kept Missed Rescheduled Kept Missed Rescheduled How are your appointments with the ID provider? More often than once a month Once every month Once every 2-3 months Once every 6 months Other:
ELECTRONIC_Standardized_Michigan_HIV_MCM_Reassessment_Pilot_Tool_2_2016_517966_7.docx