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Monthly HIV Phone Check-In
Fast, plain-language case notes from a compassionate, no-nonsense script.
Basics
Date
Time
Case Manager
Client Name
Contact Outcome:
Reached client
Left voicemail
No answer
Try again date
When you plan to try again.
Voicemail message (optional)
Well-Being
Overall health
—
good
okay
poor
Mood
—
good
okay
stressed
down
anxious
New symptoms or illness?
No
Yes
If yes, what?
ER/Urgent Care/Hospital since last month?
No
Yes
If yes, where and why?
HIV Meds
Taking HIV meds daily?
Yes
No
Missed doses this month (number)
Why? (check all that apply)
forgot
side effects
schedule
ran out
privacy
other
Side effects?
No
Yes
If yes, what?
Labs (optional)
Viral Load
CD4
Lab Date
Appointments & Access
Upcoming appointment/labs?
No
Yes
Date
needs transportation
needs scheduling help
Medication / insurance issues (check any)
refill trouble
pharmacy issue
insurance change
cost
Needs this month (check any)
food help
housing help
utility help
transportation
employment help
legal help
mental health
Safety & Substance Use
Feels safe at home/relationships?
Yes
No
If no, what is the concern?
Substance use concerns?
No
Yes
If yes, what?
Plan & Follow-Up
Referrals to make (check any)
benefits specialist
housing specialist
Ryan White services
pharmacy assistance
transportation
food pantry
utility assistance
counseling
peer support
employment services
Next check-in date
Free-text notes (optional)
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