HIV Enrollment Form
- Veronica Muthee
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 ␣␣-␣␣-␣␣␣␣ 📆 | |
Unique ID __________________________________ | |
Other Unique ID __________________________________ | |
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 | |
Entry Point - Other __________________________________ | |
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**CC 🔽 Adolescent Girls & Young Women 🔽 Client of sex worker 🔽 Fisher Folk 🔽 Long-distance truck driver 🔽 Migrant Workers 🔽 Non-intravenous drug user 🔽 Refugee 🔽 Uniformed Forces 🔽 Other | 5682506 Priority Population Types
|
Transfer-In | |
Transferring Facility __________________________________ | |
Start ART Date ␣␣-␣␣-␣␣␣␣ 📆 | |
Current ART Regimen***CC 🔽 d4T + 3TC + NVP 🔽 TDF + FTC + EFV 🔽 TDF + FTC + DTG 🔽 TDF + 3TC + NVP 🔽 TDF + 3TC + LPV/r 🔽 TDF + 3TC + EFV 🔽 TDF + 3TC + DTG + ETR + DRV + RTV 🔽 TDF + 3TC + DTG + DRV + RTV 🔽 TAF + 3TC + LPV/r 🔽 TAF + 3TC + DTG 🔽 TAF + 3TC + DRV/r 🔽 RAL + 3TC + DRV + RTV + TDF 🔽 RAL + 3TC + DRV + RTV + AZT 🔽 RAL + 3TC + DRV + RTV 🔽 ETV + 3TC + DRV + RTV 🔽 AZT + 3TC + RAL 🔽 AZT + 3TC + NVP 🔽 AZT + 3TC + LPV/r 🔽 AZT + 3TC + EFV 🔽 AZT + 3TC + DTG 🔽 AZT + 3TC + DRV + RTV + RAL 🔽 AZT + 3TC + ATV/r 🔽 ABC + 3TC + RAL 🔽 ABC + 3TC + NVP 🔽 ABC + 3TC + LPV/r 🔽 ABC + 3TC + EFV 🔽 ABC + 3TC + DTG 🔽 ABC + 3TC + DRVr 🔽 ABC + 3TC + DRV+RTV+RAL 🔽 ABC + 3TC + ATVr | HIV_Transfer_In_RegimenPatients Regimen
|
Date of Enrolment into HIV Care ␣␣-␣␣-␣␣␣␣ 📆 | |
HIV Diagnosis | |
Date Confirmed HIV Positive ␣␣-␣␣-␣␣␣␣ 📆 | |
Test Type 🔘 Rapid test for HIV 🔘 HIV DNA polymerase chain reaction 🔘 Unknown | |
Previous ARV/HAART Use |
|
Use of Pre Exposure Prophylaxis (PrEP) 🔘 Yes 🔘 No 🔘 Unknown | |
Use of Post-exposure prophylaxis (PEP)***CC 🔘 Yes 🔘 No 🔘 Unknown | 164845 Eligible for post-exposure prophylaxis
|
ART Use for Prevention of Mother to Child Transmission of HIV***CC 🔘 Yes 🔘 No 🔘 Unknown | 163532 Mother enrolled in prevention of maternal to child transmission (PMTCT) program
|
Nucleoside Reverse Transcriptase Inhibitors (NRTIS)***CC ☑️ Zidovudine ☑️ Tenofovir ☑️ Lamivudine ☑️ Emtricitabine ☑️ Abacavir ☑️ Other antiretroviral drug | NRTIS Nucleoside Reverse Transcriptase Inhibitors (NRTIS) ARVs |
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS)***CC ☑️ Etravirine ☑️ Nevirapine ☑️ Efavirenz ☑️ Other antiretroviral drug ☑️ Unknown | NNRTIS Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS) ARVs |
Protease Inhibitors (PIS)***CC ☑️ Tipranavir ☑️ Saquinavir ☑️ Ritonavir ☑️ Fosamprenavir ☑️ Darunavir ☑️ Atazanavir | |
Other HIV Drug Classes ☑️ Raltegravir ☑️ Dolutegravir ☑️ Maraviroc ☑️ Enfuvirtide ☑️ Other antiretroviral drug ☑️ Unknown | |
Treatment Supporter |
|
Treatment Supporter Name __________________________________ | |
Treatment Supporter Phone Number __________________________________ | |
Treatment Supporter Relationship 🔽 Sibling 🔽 Parent 🔽 Partner or spouse 🔽 Guardian 🔽 Grandparent 🔽 Other | |
Re-enrollment |
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Date of Re-enrollment ␣␣-␣␣-␣␣␣␣ 📆 | |
Reason For Re-enrolment __________________________________ | |