Question | Concept | |
|---|---|---|
What do you want to do? 🔘 Enrol a new client 🔘 Transfer in a client 🔘 Enrol a Mother into PMTCT program 🔘 Re-enrol a client | ||
Enrolment Date ␣␣-␣␣-␣␣␣␣ 📆 | ||
Unique ID __________________________________ | ||
Entry Point__________________________________ 🔽 Voluntary male circumcision clinic 🔽 Private home-based care 🔽 Adolescent outreach program 🔽 Private company 🔽 Outreach program 🔽 Community-based organization 🔽 Outpatient department 🔽 Pediatric inpatient service 🔽 Voluntary counseling and testing program 🔽 Maternal and child health program 🔽 Vaccination service 🔽 Nutrition program 🔽 Sex worker outreach program 🔽 Intravenous venous drug user outreach program 🔽 Sexually transmitted infection program/clinic 🔽 Under five clinic 🔽 Tuberculosis treatment program 🔽 Adult inpatient service | ||
Population Category 🔘 General population 🔘 Key population 🔘 Priority population | ||
Key Population Type 🔘 Intravenous drug user 🔘 Male who has sex with men 🔘 Prisoners 🔘 Sex worker 🔘 Transgender Persons | ||
Priority Population Type 🔽 Adolescent Girls & Young Women 🔽 Client of sex worker 🔽 Fisher Folk 🔽 Long-distance truck driver 🔽 Migrant Workers 🔽 Non-intravenous drug user 🔽 Refugee 🔽 Uniformed Forces 🔽 Other | ||
Transfer-In | ||
Transferring Facility __________________________________ | ||
Start ART Date ␣␣-␣␣-␣␣␣␣ 📆 | ||
Current ART Regimen 🔽 🔽 🔽 🔽 🔽 | ||
Transfer Documents | ||
Transfer Documents 🔘 Mother enrolled in prevention of maternal to child transmission (PMTCT) program 🔘 Transfer-in with Records 🔘 Transfer-in without records | ||
Date of Enrolment into HIV Care ␣␣-␣␣-␣␣␣␣ 📆 | ||
HIV Diagnosis | ||
Date Confirmed HIV Positive ␣␣-␣␣-␣␣␣␣ 📆 | ||
Test Type 🔘 Rapid test for HIV 🔘 HIV DNA polymerase chain reaction 🔘 Unknown | ||
Test Location __________________________________ | ||
Previous ARV/HAART Use | ||
Use of Pre Exposure Prophylaxis (PrEP) 🔘 Yes 🔘 No 🔘 Unknown | ||
Date Last Used ␣␣-␣␣-␣␣␣␣ 📆 | ||
Use of Post-exposure prophylaxis (PEP) 🔘 Yes 🔘 No 🔘 Unknown | ||
Date Last Used ␣␣-␣␣-␣␣␣␣ 📆 | ||
ARV Use for Management of Hepatitis 🔘 Yes 🔘 No 🔘 Unknown | ||
Date Last Used ␣␣-␣␣-␣␣␣␣ 📆 | ||
ART Use for Prevention of Mother to Child Transmission of HIV 🔘 Yes 🔘 No 🔘 Unknown | ||
Date Last Used ␣␣-␣␣-␣␣␣␣ 📆 | ||
Nucleoside Reverse Transcriptase Inhibitors (NRTIS) 🔽 Zidovudine 🔽 Tenofovir 🔽 Lamivudine 🔽 Emtricitabine 🔽 Abacavir 🔽 Other antiretroviral drug | ||
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS) 🔽 Etravirine 🔽 Nevirapine 🔽 Efavirenz 🔽 Other antiretroviral drug 🔽 Unknown | ||
Protease Inhibitors (PIS) 🔽 Tipranavir 🔽 Saquinavir 🔽 Ritonavir 🔽 Fosamprenavir 🔽 Darunavir 🔽 Atazanavir | ||
Other HIV Drug Classes 🔽 Raltegravir 🔽 Dolutegravir 🔽 Maraviroc 🔽 Enfuvirtide 🔽 Other antiretroviral drug 🔽 Unknown | ||
Treatment Supporter | ||
Treatment Supporter Available 🔘 Yes 🔘 No | ||
Treatment Supporter Name __________________________________ | ||
Treatment Supporter Phone Number __________________________________ | ||
Treatment Supporter Relationship 🔽 Sibling 🔽 Parent 🔽 Partner or spouse 🔽 Guardian 🔽 Grandparent 🔽 Other | ||
Re-enrollment | ||
Date of Re-enrollment ␣␣-␣␣-␣␣␣␣ 📆 | ||
Reason For Re-enrolment | ||
Test Location __________________________________ | ||
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