HIV Enrollment Formβ
JSON File: ct_service_enrolment.json
Questions | Concepts |
|---|---|
What do you want to do? π Enrol a new client π Transfer in a client π Enrol a Mother into PMTCT program π Re-enrol a client | |
Enrolment Date β£β£-β£β£-β£β£β£β£ π | |
Unique ID __________________________________ | |
Other Unique ID __________________________________ | |
Entry Point π½ Voluntary male circumcision clinic π½ Private home-based care π½ Adolescent outreach program π½ Private Company π½ Outreach program π½ Community-based organization π½ Outpatient department π½ Pediatric inpatient service π½ Voluntary counseling and testing program π½ Maternal and child health program π½ Vaccination service π½ Nutrition program π½ Sex worker outreach program π½ Intravenous venous drug user outreach program π½ Sexually transmitted infection program/clinic π½ Under five clinic π½ Tuberculosis treatment program π½ Adult inpatient service | |
Entry Point - Other __________________________________ | |
Population Category π General population π Key population π Priority population | |
Key Population Type π Intravenous drug user π Male who has sex with men π Prisoners π Sex worker π Transgender Persons | |
Priority Population Type π½ Adolescent Girls & Young Women π½ Client of sex worker π½ Fisher Folk π½ Long-distance truck driver π½ Migrant Workers π½ Non-intravenous drug user π½ Refugee π½ Uniformed Forces π½ Other | Β |
Transfer-In | |
Transferring Facility __________________________________ | |
Start ART Date β£β£-β£β£-β£β£β£β£ π | |
Regimen π½ ABC + 3TC + DTG | 164432 ARV regimen/code for drugs collected
|
Date of Enrolment into HIV Care β£β£-β£β£-β£β£β£β£ π | |
HIV Diagnosis | |
Date Confirmed HIV Positive β£β£-β£β£-β£β£β£β£ π | |
Test Type π Rapid test for HIV π HIV DNA polymerase chain reaction π Unknown | |
Previous ARV/HAART Use | Β |
Indication/intent of therapy βοΈ Pre Exposure Prophylaxis (PrEP) βοΈ Prevention of Mother to Child Transmission (PMTCT) βοΈ Post-exposure prophylaxis (PEP) | |
Use of Pre Exposure Prophylaxis (PrEP) | |
Use of Post-exposure prophylaxis (PEP)***CC | |
ART Use for Prevention of Mother to Child Transmission of HIV***CC | 163532 Mother enrolled in prevention of maternal to child transmission (PMTCT) program |
Nucleoside Reverse Transcriptase Inhibitors (NRTIS)***CC | NRTIS Nucleoside Reverse Transcriptase Inhibitors (NRTIS) ARVs |
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS)***CC | NNRTIS Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS) ARVs |
Protease Inhibitors (PIS)***CC | ProteaseInhibitorsProtease Inhibitors (PIS) ARVs |
Other HIV Drug Classes | 1193 Current drugs used |
Treatment Supporter | Β |
Treatment Supporter Name __________________________________ | |
Treatment Supporter Phone Number __________________________________ | |
Treatment Supporter Relationship π½ Sibling π½ Parent π½ Partner or spouse π½ Guardian π½ Grandparent π½ Other | |
Re-enrollment | Β |
Date of Re-enrollment β£β£-β£β£-β£β£β£β£ π | |
Reason For Re-enrolment __________________________________ | |