Disclosure Form✅

Date of Disclosure

␣␣-␣␣-␣␣␣␣ 📆

160753 Date of event

Stage of disclosure

🔘 HIV Pre-disclosure

🔘 Partial disclosure

🔘 Full disclosure: Stage 1

🔘 Full disclosure: Stage 2

🔘 Full disclosure: Stage 3

🔘 Full disclosure: Stage 4

169422 Stage of HIV disclosure

• 169421 HIV pre-disclosure

• 169420 Partial HIV disclosure

• 169416 Full HIV disclosure, stage 1

• 169417 Full HIV disclosure, stage 2

• 169418 Full HIV disclosure, stage 3

• 169419 Full HIV disclosure, stage 4

Disclosure Notes

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165095 General patient note