...
| Panel | ||||||
|---|---|---|---|---|---|---|
| ||||||
JSON File: ct_service_enrolment.json |
Questions | Concepts | |||
|---|---|---|---|---|
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 __________________________________ | ||||
Other Unique ID __________________________________ | ||||
Entry Point 🔽 Voluntary male circumcision clinic 🔽 Private home-based care 🔽 Adolescent outreach program 🔽 Private companyCompany 🔽 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 | ||||
Entry Point - Other __________________________________ | ||||
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 | 2bf14240-b2b2-42b2-8cf3-b5f8a0cb7764 5682506 Priority Population Types166433 Target population type | |||
Transfer-In | ||||
Transferring Facility __________________________________ | ||||
Start ART Date ␣␣-␣␣-␣␣␣␣ 📆 | ||||
Current ART Regimen*** 🔽 d4T ABC + 3TC + NVPDTG 🔽 ABC + 3TC + DTG 🔽 ABC + 3TC + DRVr 🔽 ABC + 3TC + DRV+RTV+RAL 🔽 ABC + 3TC + ATVr | dfbe256e-30ba-4033-837a-2e8477f2e7cd |
|
| 164432 ARV regimen/code for drugs collected
|
Date of Enrolment into HIV Care ␣␣-␣␣-␣␣␣␣ 📆 | ||||
HIV Diagnosis | ||||
Date Confirmed HIV Positive ␣␣-␣␣-␣␣␣␣ 📆 | ||||
Test Type*** 🔘 Rapid test for HIV 🔘 HIV DNA polymerase chain reaction 🔘 Unknown |
| |||
Previous ARV/HAART Use | ||||
Indication/intent of therapy ☑️ Pre Exposure Prophylaxis (PrEP) ☑️ Prevention of Mother to Child Transmission (PMTCT) ☑️ Post-exposure prophylaxis (PEP) | ||||
Use of Pre Exposure Prophylaxis (PrEP) |
|
| ||
Use of Post-exposure prophylaxis (PEP)****CC | ||||
|
| |||
|
| |||
|
| |||
ART Use for Prevention of Mother to Child Transmission of HIV***CC | 163532 Mother enrolled in prevention of maternal to child transmission (PMTCT) program |
|
| |
Nucleoside Reverse Transcriptase Inhibitors (NRTIS)***CC | NRTIS Nucleoside Reverse Transcriptase Inhibitors (NRTIS) ARVs | |||
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS)***CC | 9064043b-5b18-4228-97ff-f0e20aaf9448 NNRTIS Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS) ARVs | |||
Protease Inhibitors (PIS)***CC | ProteaseInhibitorsProtease Inhibitors (PIS) ARVs | |||
Other HIV Drug Classes*** | Treatment Supporter |
|
| |
Treatment Supporter | ||||
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 __________________________________ | ||||