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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 ␣␣-␣␣-␣␣␣␣ 📆 | 160555AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |||
Unique ID __________________________________ | ||||
Other Unique ID __________________________________ | 162576AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA162727 Other facility patient identifier | |||
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 service160540AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAdult inpatient service | ||||
Entry Point - Other __________________________________ | ||||
Population Category 🔘 General population 🔘 Key population 🔘 Priority population746737c0 | -4201-4d7f-b580-816e36dc425a166432 Study population type | |||
Key Population Type 🔘 Intravenous drug user 🔘 Male who has sex with men 🔘 Prisoners 🔘 Sex worker 🔘 Transgender Personsd3d4ae96 | -8c8a-43db-a9dc-dac951f5dcb3166433 Target population type | |||
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 🔽 Other2bf14240-b2b2-42b2-8cf3-b5f8a0cb7764 | ||||
Transfer-In | ||||
Transferring Facility __________________________________ | 160535AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA160535 Transferred from location | |||
Start ART Date ␣␣-␣␣-␣␣␣␣ 📆 | 159599AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | Current ART 159599 Antiretroviral treatment start date | ||
Regimen 🔽 d4T ABC + 3TC + NVPDTG 🔽 ABC + 3TC + DTG 🔽 ABC + 3TC + DRVr 🔽 ABC + 3TC + DRV+RTV+RAL 🔽 ABC + 3TC + ATVr | dfbe256e-30ba-4033-837a-2e8477f2e7cd | Transfer Documents 🔘 Mother enrolled in prevention of maternal to child transmission (PMTCT) program 🔘 Transfer-in with Records 🔘 Transfer-in without records | 7962d0ed-0fb5-4580-8e46-6fd318091154NVP | 164432 ARV regimen/code for drugs collected
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Date of Enrolment into HIV Care ␣␣-␣␣-␣␣␣␣ 📆 | 163260AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA163260 Date of first visit | |||
HIV Diagnosis | ||||
Date Confirmed HIV Positive ␣␣-␣␣-␣␣␣␣ 📆 | 160554AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA160554 Date of HIV diagnosis | |||
Test Type 🔘 Rapid test for HIV 🔘 HIV DNA polymerase chain reaction 🔘 Unknown | ca4953af-9ad4-4514-b54a-6832acd7cae9 | Test Location __________________________________ | c4768674-0c26-4353-8a3f-608e7b40ac57164401 HIV test performed | |
Previous ARV/HAART Use | ||||
Use of Indication/intent of therapy ☑️ Pre Exposure Prophylaxis (PrEP) 🔘 Yes 🔘 No 🔘 Unknown | 5d397775-0155-4033-95dc-edcec98e8190 | |||
Date Last Used ␣␣-␣␣-␣␣␣␣ 📆 | 5af829e9-2427-4ed7-bb55-de4381610364 | |||
Use of Post-exposure prophylaxis (PEP☑️ Prevention of Mother to Child Transmission (PMTCT) ☑️ Post-exposure prophylaxis (PEP) | ||||
Use of Pre Exposure Prophylaxis (PrEP) | 8bfdc328-1970-446c-9d7b-97d62703801b | |||
Date Last Used ␣␣-␣␣-␣␣␣␣ 📆 | fbe937b6-a4ad-4ce5-9c43-002222fbabfb | |||
ARV Use for Management of Hepatitis166655 Pre-exposure prophylaxis (PrEP) regimen | ||||
Use of Post-exposure prophylaxis (PEP)***CC | 906ed69c-949b-47b5-b469-2205f0da473a | Date Last Used ␣␣-␣␣-␣␣␣␣ 📆 | 6a6cbda5-b155-4144-9ff9-ec3d1d1cd509164845 Eligible for post-exposure prophylaxis | |
ART Use for Prevention of Mother to Child Transmission of HIV***CC | 163532AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | Date Last Used ␣␣-␣␣-␣␣␣␣ 📆 | 163782AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA163532 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-f0e20aaf9448NNRTIS Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS) ARVs | |||
Protease Inhibitors (PIS)***CC | 77eed025-0f5c-4173-bf45-36e05a175aafProteaseInhibitorsProtease Inhibitors (PIS) ARVs | |||
Other HIV Drug Classes | 3509e1d9-93d0-4a6b-b5cb-90259699b01a | Treatment Supporter | Treatment Supporter Available 🔘 Yes 🔘 No | 0a540601-8cc4-4d18-9360-d760780f3eb11193 Current drugs used |
Treatment Supporter | ||||
Treatment Supporter Name __________________________________ | 160638AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA160638 Name of treatment supporter | |||
Treatment Supporter Phone Number __________________________________ | 160642AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA160642 Telephone number of treatment supporter | |||
Treatment Supporter Relationship 🔽 Sibling 🔽 Parent 🔽 Partner or spouse 🔽 Guardian 🔽 Grandparent 🔽 Other160640AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | ||||
Re-enrollment | ||||
Date of Re-enrollment ␣␣-␣␣-␣␣␣␣ 📆20efadf9-86d3-4498-b3ab-7da4dad9c429 | ||||
Reason For Re-enrolment __________________________________ | 14ae2dc9-5964-425a-87e8-9ca525cf055e160632 Free text general | |||