Questions | Concepts | |
|---|---|---|
Patient Details | ||
Encounter date ␣␣-␣␣-␣␣␣␣ 📆 | ||
Encounter Provider | ||
Role | ||
Scheduled visit (boolean) 🔘 Yes 🔘 No | ||
Visit type 🔘 Express pharmacy pickup without clinician visit 🔘 Follow-up Visit, Regular | ||
Population Category 🔘 General population 🔘 Key population 🔘 Priority population | ||
Key Population Type 🔘 Intravenous drug user 🔘 Man 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 | ||
Complaints and History of Complaints | ||
|
| |
History of Presenting Complaints ☑️ Abdominal pain ☑️ Back pain ☑️ Chest pain ☑️ Cough ☑️ Chills ☑️ Confusion ☑️ Convulsions ☑️ Depression ☑️ Diarrhea ☑️ Discharge from Penis ☑️ Dizziness and Giddiness ☑️ Ear Problem ☑️ Epigastric pain ☑️ Excessive Sweating ☑️ Facial Pain ☑️ Fever ☑️ Flank Pain ☑️ Headache ☑️ Hearing Loss ☑️ Itching ☑️ Leg Pain ☑️ Loss of Appetite ☑️ Memory Loss ☑️ Lethargy ☑️ Mouth ulceration ☑️ Muscle pain ☑️ Nausea ☑️ Neck Pain ☑️ Night sweats ☑️ Numbness of Foot ☑️ Pain in Eye ☑️ Pain in Joint ☑️ Pain in pelvis ☑️ Pain in Scrotum ☑️ Pain of Breast ☑️ Painful Mouth ☑️ Rash ☑️ Red eye ☑️ Rectal discharge ☑️ Rhinitis ☑️ Seizure ☑️ Shortness of breath ☑️ Shoulder Pain ☑️ Sore throat ☑️ Swallowing Painful ☑️ Swollen Feet ☑️ Tremor ☑️ Urinary symptoms ☑️ Vaginal bleeding ☑️ Vaginal discharge ☑️ Vision difficulties ☑️ Vomiting ☑️ Weight loss | 1390 History of present illness | |
Onset Date ␣␣-␣␣-␣␣␣␣ 📆 | ||
Duration (Days) __________________________________ | ||
Chief complaint (text) __________________________________ | ||
Past Medication History | ||
Past medical & Surgical history narrative __________________________________ | ||
Current TPT/ TB Treatment | ||
Currently on treatment for tuberculosis | ||
Currently on tuberculosis prophylaxis treatment (TPT) | ||
Previously completed Tuberculosis preventive treatment | ||
Allergies & Adverse Drug Reactions | ||
AAllergies | workspace-launcher | |
Patient reports adverse drug reaction(s)? 🔘 Yes 🔘 No 🔘 Unknown | ||
Medicine Causing Reaction | ||
Reaction Anaphylaxis Angioedema Anaemia Arrhythmia Bronchospasm Cough Diarrhea Dystonia Flu-Like Syndrome Flushing Fever GI upset***159581AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Nausea Hypertension Hives Headache Hepatotoxicity Hyperuricemia Itching Mental status change Musculoskeletal pain Optic Neuritis Shortness of breath Rash Tendon Rupture Visual Disturbances Vomiting Unknown Other | 160646 Reaction (to an allergen) | |
Severity 🔘 Not graded 🔘 Mild 🔘 Moderate 🔘 Severe 🔘 Life-threatening | ||
Date of Onset | ||
Action taken 🔘 Continue drug 🔘 Dose adjusted 🔘 Discontinued 🔘 Substitution | ||
Family History | ||
Family History Narrative | ||
Sexual History | ||
Sexually active? 🔘 Yes 🔘 No 🔘 Currently not sexually active | ||
Sex without a condom 🔘 Yes 🔘 No 🔘 Unknown | ||
Recent history of a Sexually Transmitted Infection 🔘 Yes 🔘 No 🔘 Unknown | ||
Reproductive History*** | ||
Social History | ||
History of Substance Use (Alcohol, Tobacco, Drugs) 🔘 Never 🔘 Current/Past use | ||
Do you smoke cigarettes 🔘 Never smoker 🔘 Unknown if ever smoked 🔘 Smoker 🔘 Former smoker | ||
Number of years smoked | ||
Number of cigarette per day | ||
Alcohol use 🔘 Never 🔘 Currently 🔘 In the past | ||
Duration in Years**** | ||
Substances abused***** ☑️ None ☑️ Barbiturate abuse ☑️ Cannabis Abuse ☑️ Cocaine abuse ☑️ Inhalant abuse ☑️ Khat abuse ☑️ Narcotic abuse ☑️ Opioid abuse | ||
History of Recent Travel? 🔘 Yes 🔘 No | ||
Subjective narrative*** | 61675c28-e628-4173-bc65-d5e0df78a6da | |
Immunization History | ||
Immunizations | workspace-launcher | |
Objective History | ||
General examination findings ☑️ Normal ☑️ Cyanosis ☑️ Dehydration ☑️ Finger Clubbing ☑️ Jaundice ☑️ Lethargic ☑️ Lymph Node Axillary ☑️ Lymph Nodes Inguinal ☑️ Oral thrush ☑️ Oedema ☑️ Wasting ☑️ Nasal Flaring ☑️ Pallor | ||
General Examination Notes | ||
Systemic Examination | ||
Physical exam outcome 🔘 Normal 🔘 Abnormal | ||
Reviews of System ☑️ Abdominal ☑️ Cardiovascular ☑️ Central Nervous System ☑️ Head, Ear, Eye, Nose & Throat ☑️ Genitourinary ☑️ Musculoskeletal ☑️ Respiratory ☑️ Skin | ||
Abdomen findings ☑️ Abdominal distension ☑️ Abdominal mass ☑️ Splenomegaly ☑️ Hepatomegaly ☑️ Abdominal tenderness | ||
Abdomen findings notes | ||
CVS findings ☑️ Cardiac murmur ☑️ Cardiac rub ☑️ Elevated blood pressure ☑️ Irregular heartbeat ☑️ Palpitations | ||
CVS findings notes | ||
CNS findings ☑️ Abnormal reflexes ☑️ Altered sensations ☑️ Brudzinski's sign ☑️ Bulging fontenelle ☑️ Confusion ☑️ Kernicterus ☑️ Limb weakness ☑️ Loss of consciousness ☑️ Stiff neck | ||
CNS findings notes | ||
Genitourinary findings ☑️ Bleeding ☑️ Genital rashes/Lesions ☑️ Hypospadias ☑️ Inguinal Swelling ☑️ Rectal discharge ☑️ Scrotal mass ☑️ Testicular mass ☑️ Ulceration ☑️ Urethral discharge ☑️ Vaginal discharge ☑️ Genital Warts | ||
Genitourinary findings notes | ||
HEENT findings ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ ☑️ | ||
HEENT findings notes | ||
Musculoskeletal findings ☑️ Abnormal Posture/Movement ☑️ Deformity ☑️ Pain in Joints ☑️ Heberdens nodes ☑️ Increased of local temperature ☑️ Joint crepitus ☑️ Joint stiffness ☑️ Swelling ☑️ Muscle Wasting ☑️ Muscle weakness ☑️ Pitting/Non pitting oedema ☑️ Restriction of movement ☑️ Tendon sheath crepitus ☑️ Ulcers | 1128 Musculoskeletal exam findings | |
Musculoskeletal findings notes | ||
Respiratory findings ☑️ Reduced breathing ☑️ Bronchial breathing ☑️ Chest in-drawing ☑️ Crackles ☑️ Dullness ☑️ Grunting ☑️ Respiratory distress ☑️ Stridor ☑️ Wheezing | ||
Respiratory findings notes | ||
Skin findings ☑️ Abscess ☑️ Hair Loss ☑️ Itching ☑️ Kaposis Sarcoma ☑️ Swelling/Growth ☑️ Skin eruptions/Rashes ☑️ Ulcer | ||
Skin findings notes | ||
WHO HIV Stage | ||
Current WHO HIV stage 🔘 Unknown 🔘 WHO stage 1 🔘 WHO stage 2 🔘 WHO stage 3 🔘 WHO stage 4 | ||
Nutritional status 🔘 Not done 🔘 Normal 🔘 Severe acute malnutrition 🔘 Moderate acute malnutrition 🔘 Obesity | ||
Conditions List  | conditions-form-workspace | |
Allergies  | patient-allergy-form-workspace | |
Patient reports adverse drug reaction(s)? 🔘 Yes 🔘 No 🔘 Unknown | 162867AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
OBGYN History | ||
Current menstruation status 🔘 Amenorrhea 🔘 Currently pregnant 🔘 Menstruating | 082ddc79-e355-4344-a4f8-ee458c15e3ef | |
LMP ␣␣-␣␣-␣␣␣␣ 📆 | 166079AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Intend to conceive in the next three months? 🔘 Yes 🔘 No 🔘 Unknown | 9109b9f3-8176-4d2f-b47d-82630dcc02ce | |
Breastfeeding 🔘 Yes 🔘 No 🔘 Unknown | 5632AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Family planning method 🔘 Patient not using family planning 🔘 Currently using birth control 🔘 Requests family planning information | 160653AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Preferred family planning method 🔽 Condoms 🔽 Diaphragm 🔽 Emergency contraceptive pills 🔽 Female condom 🔽 Female sterilization 🔽 Hysterectomy 🔽 Implantable contraceptive 🔽 Injectable contraceptives 🔽 Intrauterine device 🔽 Lactational amenorrhea 🔽 Levonorgestrel 🔽 Male condom 🔽 Medroxyprogesterone acetate 🔽 Natural family planning 🔽 Norplant (implantable contraceptive) 🔽 Oral contraception 🔽 Sexual abstinence 🔽 Tubal ligation procedure 🔽 Vasectomy 🔽 Other non-coded | 374AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Reason not on family planning 🔽 Currently not sexually active 🔽 Patient thinks she can't get pregnant 🔽 Patient wishes to get pregnant | 160575AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
EDD ␣␣-␣␣-␣␣␣␣ 📆 | 5596AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Gestational age (weeks) | 1438AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Antenatal profile done 🔘 Yes 🔘 No | 975f11e5-7471-4e57-bba7-d3ee358ef7ea | |
Screened for cervical cancer during this visit 🔘 Cervical cancer screening not performed 🔘 Cervical cancer screening performed | 975f11e5-7471-4e57-bba7-d3ee358ef7ea | |
Date last screened for cervical cancer ␣␣-␣␣-␣␣␣␣ 📆 | 165429AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Cervical cancer screening method ☑️ Colposcopy ☑️ Human Papillomavirus test ☑️ Papanicolaou smear ☑️ Visual Inspection of the Cervix with Acetic Acid (VIA) ☑️ Visual Inspection of the Cervix with Lugol’s Iodine (VILI) | 53ff5cd0-0f37-4190-87b1-9eb439a15e94 | |
Treatment of cervical pre-cancer lesions 🔘 Cold knife cone biopsy of cervix 🔘 Cryosurgery of lesion of cervix 🔘 Hysterectomy 🔘 Loop electrosurgical excision procedure of cervix 🔘 Thermocauterization of cervix 🔘 Other non-coded 🔘 None | 3a8bb4b4-7496-415d-a327-57ae3711d4eb | |
Tuberculosis | ||
Currently on treatment for tuberculosis 🔘 Yes 🔘 No 🔘 Unknown | 159798AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Currently on tuberculosis prophylaxis treatment (TPT) 🔘 Yes 🔘 No 🔘 Unknown | 166449AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Previously completed Tuberculosis preventive treatment 🔘 Yes 🔘 No 🔘 Unknown | 166463AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
TB screening done? 🔘 Yes 🔘 No 🔘 Unknown | f8868467-bd15-4576-9da8-bfb8ef64ea17 | |
Adult TB Intensive Case Finding ☑️ Night sweats ☑️ Fever lasting more than three weeks ☑️ Cough lasting more than 2 weeks ☑️ Weight Loss (Abnormal weight loss) ☑️ None | 12a22a0b-f0ed-4f1a-8d70-7c6acda5ae78 | |
Peads TB Intensive Case Finding ☑️ History of contact with a person with TB ☑️ Fever lasting more than three weeks ☑️ Cough lasting more than 2 weeks ☑️ Failure to Gain Weight ☑️ None | 16ba5f4b-5430-44c8-91e4-c4c66b072f29 | |
TB screening outcome 🔘 Negative 🔘 Positive (Presumptive TB) | 160108AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Evaluated for tuberculosis prophylaxis 🔘 Not applicable 🔘 Yes 🔘 No | 162275AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Tuberculosis prophylaxis plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 Stop all | 1265AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Tuberculosis preventive treatment regimen 🔽 1 HP Isoniazide + Rifapentine prophylaxis 🔽 3HP Rifapentine + Isoniazid 🔽 3HR Isoniazid+Rifampicin prophylaxis 🔽 4R Rifampicin Monotherapy prophylaxis 🔽 6H Isoniazid prophylaxis 🔽 9H Isoniazid prophylaxis | 90c9e554-b959-48e6-90d5-8d595a074c86 | |
Date tuberculosis prophylaxis started ␣␣-␣␣-␣␣␣␣ 📆 | 162320AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Tuberculosis Preventive Treatment adherence 🔘 Good 🔘 Poor 🔘 Fair 🔘 Unknown | 161653AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Date tuberculosis prophylaxis ended ␣␣-␣␣-␣␣␣␣ 📆 | 163284AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Reason tuberculosis prophylaxis stopped 🔘 Completed 🔘 Toxicity, drug 🔘 Tuberculosis 🔘 Other non-coded | 1266AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Tuberculosis treatment plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 Change regimen 🔘 Dosing Change 🔘 Stop all | 1268AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Tuberculosis drug treatment start date ␣␣-␣␣-␣␣␣␣ 📆 | 1113AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Tuberculosis treatment end date ␣␣-␣␣-␣␣␣␣ 📆 | 159431AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Action taken - Presumptive TB ☑️ GeneXpert MTB/Rif Ordered ☑️ Sputum for acid fast bacilli ordered ☑️ X-ray, chest ordered | a39dfa34-a139-4335-9eac-219d6fedf868 | |
Notes __________________________________ | 163323AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Physical/Systemic Exam | ||
General Exam (On Exam) ☑️ Anaemia ☑️ Clubbing ☑️ Candidiasis, oral ☑️ Cyanosis ☑️ Dehydration ☑️ Jaundice ☑️ Lymphadenopathy ☑️ Oedema ☑️ Lethargy ☑️ Pallor ☑️ Severely wasted ☑️ Normal ☑️ Not assessed ☑️ Other non-coded | b78e20ec-0833-4e87-969b-760a29864be8 | |
General Examination Notes __________________________________ | 163042AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Lympadenopathy ☑️ Submandibular ☑️ Cervical ☑️ Supraclavicular ☑️ Axillary ☑️ Inguinal | 1121AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
HEENT (head, eyes, ears, nose, and throat) 🔘 Normal 🔘 Abnormal 🔘 Not assessed | 33b614d0-1953-4056-ac84-66b0492394e5 | |
HEENT examination findings (Text) __________________________________ | 163045AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Respiratory Systems review 🔘 Normal 🔘 Abnormal 🔘 Not assessed | f089c930-1c55-4ab6-934e-f7e7eca6f4e0 | |
Respiratory System Findings (Text) __________________________________ | 160689AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Cardiovascular Systems review 🔘 Normal 🔘 Abnormal 🔘 Not assessed | 3909220e-0d0e-4547-a54e-fecd619cd861 | |
Cardiovascular examination finding (Text) __________________________________ | 163046AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Gastrointestinal System review 🔘 Normal 🔘 Abnormal 🔘 Not assessed | 3fc7236b-2b72-4a52-8286-881ea2c8dbc7 | |
Abdominal examination finding (Text) __________________________________ | 160947AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Central nervous system review 🔘 Normal 🔘 Abnormal 🔘 Not assessed | 14d61422-5323-4706-9152-781ce59c90de | |
CNS examination finding (text) __________________________________ | 163109AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Musculoskeletal system review 🔘 Normal 🔘 Abnormal 🔘 Not assessed | c6665eb5-23a9-4add-9f39-d44e42a4e5b1 | |
Musculoskeletal examination finding (Text) __________________________________ | 163048AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Genito-urinary system - ROS/PE 🔘 Normal 🔘 Abnormal 🔘 Not assessed | bd337c08-384a-47b5-88c9-fb0a67e316bd | |
Genito-urinary system examination finding (text) __________________________________ | 163047AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Screened for STIs in current visit 🔘 Yes 🔘 No 🔘 Unknown | 161558AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
STI screening findings 🔘 Genital Sore 🔘 Lower abdominal pain 🔘 Scrotal Mass 🔘 Urethral Discharge 🔘 Vaginal discharge 🔘 Normal | 118990AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Current WHO HIV stage 🔘 WHO stage 1 peds 🔘 WHO stage 2 peds 🔘 WHO stage 3 peds 🔘 WHO stage 4 peds 🔘 WHO stage 1 adult 🔘 WHO stage 2 adult 🔘 WHO stage 3 adult 🔘 WHO stage 4 adult 🔘 Unknown | 5356AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Nutritional status 🔘 Not done 🔘 Normal 🔘 Severe acute malnutrition 🔘 Moderate acute malnutrition 🔘 Obesity | c481f80d-7553-41ab-94ca-efddb8ab294c | |
Nutritional interventions provided 🔘 Yes 🔘 No 🔘 Unknown | 1380AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Nutritional support ☑️ Counseling about infant feeding practices ☑️ Food support ☑️ Micronutrient support ☑️ Therapeutic feeding ☑️ Other (specify) ☑️ None | 5484AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Nutritional plan (text) __________________________________ | 163189AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Management | ||
New/Active opportunistic infection 🔘 None 🔘 Opportunistic Infectious Present 🔘 Unknown | c52ecf45-bd6c-43ed-861b-9a2714878729 | |
Current opportunistic infections ☑️ Candidiasis, oral ☑️ Cerebral Cryptococcosis ☑️ Cervical Intraepithelial Neoplasm ☑️ Coccidioidomycosis ☑️ Cytomegalovirus infection ☑️ Encephalopathy ☑️ Hepatitis B ☑️ Hepatitis C virus infection ☑️ Herpes simplex type 2 ☑️ Herpes zoster ☑️ Histoplasmosis ☑️ Infection due to Candida Albicans ☑️ Kaposi sarcoma oral ☑️ Leukoencephalopathy ☑️ Malignant Lymphoma ☑️ Meningitis, cryptococcal ☑️ Mycobacterium tuberculosis ☑️ Pneumocystis carinii pneumonia ☑️ Pneumonia ☑️ Pulmonary Cryptococcosis ☑️ Recurrent Upper Respiratory Tract Infection ☑️ Salmonella Septicaemia ☑️ Toxoplasmosis ☑️ Wasting syndrome | 6bdf2636-7da1-4691-afcc-5eede094138f | |
Pneumocystis pneumonia prophylaxis plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 Change regimen 🔘 Stop all | 1261AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
PCP prophylaxis start date ␣␣-␣␣-␣␣␣␣ 📆 | 164361AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
PCP prophylaxis regimen 🔘 Sulfamethoxazole / trimethoprim 🔘 Dapsone | 1109AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
PCP regimen adherence 🔘 Good 🔘 Fair 🔘 Poor 🔘 Unknown | 166462AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Reason for stopping PCP prophylaxis 🔘 CD4 count greater than 15% 🔘 CD4 count greater than 200 🔘 Toxicity, drug 🔘 Other non-coded | 1262AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Cryptococcal prophylaxis plan 🔘 None 🔘 Start drugs 🔘 Continue regimen 🔘 Stop all | 1277AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Fluconazole start date ␣␣-␣␣-␣␣␣␣ 📆 | 5ac4300a-5e19-45c8-8692-31a57d6d5b8c | |
Fluconazole stop date ␣␣-␣␣-␣␣␣␣ 📆 | c2d57bcb-02f2-457d-af05-8d759a1457a7 | |
HAART adherence assessment 🔘 Good 🔘 Fair 🔘 Poor 🔘 Unknown | da4e1fd2-727f-4677-ab5f-44058555052c | |
Reason for Fair/Poor adherence to HAART 🔽 Alcohol abuse 🔽 Concerned about privacy/stigma 🔽 Depression 🔽 Felt better and stopped taking medication 🔽 Felt too ill to take medication 🔽 Forgot to take medication 🔽 Lost or ran out of medication 🔽 Pill burden 🔽 Shares medications with others 🔽 Toxicity, drug 🔽 Transport problems 🔽 Other non-coded | 160582AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Labs and Drugs Orders | workspace-launcher | |
Clinical Notes __________________________________ | 165095AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
ARV dispensing quantity (in days) __________________________________ | 3a0709e9-d7a8-44b9-9512-111db5ce3989 | |
Patient referred for other services 🔘 Yes 🔘 No | 1648AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Reason for referral ☑️ Alcohol counseling ☑️ Dental care referral ☑️ Disclosure counseling ☑️ Family planning services ☑️ Inpatient care or hospitalization ☑️ Maternal and child health program ☑️ Mental health services ☑️ Nutritional support ☑️ Ophthalmology referral ☑️ Psychosocial counseling ☑️ Referral for opportunistic infection treatment ☑️ Sexually transmitted infection program/clinic ☑️ Social support services ☑️ Surgical Outpatient Department ☑️ Referral for imaging study ☑️ Obstetrics and gynecology department ☑️ Other non-coded | 1272AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Referral comments __________________________________ | 164359AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Next Appointment Date ␣␣-␣␣-␣␣␣␣ 📆 | 5096AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Date medication refill is due ␣␣-␣␣-␣␣␣␣ 📆 | 162549AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Attending clinician's name __________________________________ | 1473AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
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