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	83e40f2c-c316-43e6-a12e-20a338100281
Enrolment Date ␣␣-␣␣-␣␣␣␣ 📆	160555AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Unique ID __________________________________	162576AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
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	160540AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Population Category 🔘 General population 🔘 Key population 🔘 Priority population	746737c0-4201-4d7f-b580-816e36dc425a
Key Population Type 🔘 Intravenous drug user 🔘 Male who has sex with men 🔘 Prisoners 🔘 Sex worker 🔘 Transgender Persons	d3d4ae96-8c8a-43db-a9dc-dac951f5dcb3
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
Transfer-In
Transferring Facility __________________________________	160535AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Start ART Date ␣␣-␣␣-␣␣␣␣ 📆	159599AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Current ART Regimen 🔽 🔽 🔽 🔽 🔽	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-0fb5-4580-8e46-6fd318091154
Date of Enrolment into HIV Care ␣␣-␣␣-␣␣␣␣ 📆	163260AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
HIV Diagnosis
Date Confirmed HIV Positive ␣␣-␣␣-␣␣␣␣ 📆	160554AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Test Type 🔘 Rapid test for HIV 🔘 HIV DNA polymerase chain reaction 🔘 Unknown	ca4953af-9ad4-4514-b54a-6832acd7cae9
Test Location __________________________________	c4768674-0c26-4353-8a3f-608e7b40ac57
Previous ARV/HAART Use
Use of Pre Exposure Prophylaxis (PrEP) 🔘 Yes 🔘 No 🔘 Unknown	5d397775-0155-4033-95dc-edcec98e8190
Date Last Used ␣␣-␣␣-␣␣␣␣ 📆
Use of Post-exposure prophylaxis (PEP) 🔘 Yes 🔘 No 🔘 Unknown	8bfdc328-1970-446c-9d7b-97d62703801b
Date Last Used ␣␣-␣␣-␣␣␣␣ 📆
ARV Use for Management of Hepatitis 🔘 Yes 🔘 No 🔘 Unknown	906ed69c-949b-47b5-b469-2205f0da473a
Date Last Used ␣␣-␣␣-␣␣␣␣ 📆
ART Use for Prevention of Mother to Child Transmission of HIV 🔘 Yes 🔘 No 🔘 Unknown	163532AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
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	0a540601-8cc4-4d18-9360-d760780f3eb1
Treatment Supporter Name __________________________________	160638AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Treatment Supporter Phone Number __________________________________	160642AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Treatment Supporter Relationship 🔽 Sibling 🔽 Parent 🔽 Partner or spouse 🔽 Guardian 🔽 Grandparent 🔽 Other	160640AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Re-enrollment
Date of Re-enrollment ␣␣-␣␣-␣␣␣␣ 📆	20efadf9-86d3-4498-b3ab-7da4dad9c429
Reason For Re-enrolment __________________________________	14ae2dc9-5964-425a-87e8-9ca525cf055e