Get Apla Physician Diagnosis Form

Completing the APLA Physician Diagnosis Form online is a crucial step in ensuring proper documentation of a patient's diagnosis and care. This guide will provide clear and detailed instructions to assist you in filling out the form accurately.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. In the patient information section, enter the last name, first name, and middle name of the individual. Provide the date of birth and the social security number.
3. Indicate the diagnosis by selecting only one option: HIV+ Asymptomatic, AIDS Asymptomatic, HIV+ Symptomatic, or AIDS Symptomatic. Also, fill in the date of this diagnosis.
4. If applicable, provide the year of the first positive test for HIV and list any symptoms that substantiate the diagnosis by checking the relevant boxes and including additional symptoms if necessary.
5. List any opportunistic infections associated with the diagnosis by checking the appropriate boxes.
6. Fill in the current symptoms related to HIV disease or treatment in the provided space.
7. Enter the lab data, including CD4 cell count, CD4 percentage, and HIV viral load, along with the respective dates.
8. Respond to the question regarding other illnesses by providing relevant details in the space provided.
9. Conduct a Karnofsky scale assessment by checking the appropriate numerical value that reflects the patient’s current condition.
10. Answer the questions regarding skilled nursing care and dental care eligibility as needed.
11. Answer the tuberculosis screening questions, providing all relevant details such as dates of tests.
12. The physician responsible for the patient's care must sign and date the form at the bottom, including their name, CA license number, address, and phone number.
13. Finally, review all entries for accuracy, save your changes, and download or print the completed form as necessary.

Take the next step in managing patient care by completing the APLA Physician Diagnosis Form online.