HIV Enrollment Form

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 __________________________________
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 🔽 🔽 🔽 🔽
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 🔽 🔽 🔽 🔽 🔽
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS) 🔽 🔽 🔽 🔽 🔽
Protease Inhibitors (PIS) 🔽 🔽 🔽 🔽 🔽
Other HIV Drug Classes 🔽 🔽 🔽 🔽 🔽
Treatment Supporter
Treatment Supporter Available 🔘 Yes 🔘 No
Treatment Supporter Name __________________________________
Treatment Supporter Phone Number __________________________________
Treatment Supporter Relationship 🔽 🔽 🔽 🔽
Re-enrollment
Date of Re-enrollment ␣␣-␣␣-␣␣␣␣ 📆
Reason For Re-enrolment
Test Location __________________________________