Patient Tracing Form

Contact Date

␣␣-␣␣-␣␣␣␣ 📆

Contact Method

🔘 Physical contact/client tracing

🔘 Telephone contact/client tracing

🔘 Other non-coded

Contacted Successfully

🔘 Yes

🔘 No

🔘 Unknown

Reasons for missing an appointment

🔽 Client could not get an off from work/school

🔽 COVID-19 Restrictions

🔽 Exposure to COVID-19

🔽 Had enough medications

🔽 Felt better and stopped taking medication

🔽 Inpatient care or hospitalization

🔽 Patient forgot to attend appointment

🔽 Patient was seen in another health center

🔽 Traveling

🔽 Other

Expected Return Date

␣␣-␣␣-␣␣␣␣ 📆

Outcome

Final Tracing Outcome reached (After successful or multiple unsuccessful tracing attempts)

🔘 Yes

🔘 No

Final tracing outcome - Patient

🔘 Dead (Create a Death Form)

🔘 Undocumented/Silent transfer-out (Create a Transfer-Out Form)

🔘 Refused (stopped) treatment (Update ART Therapy Form)

🔘 Interruption in Treatment (Lost to follow-up)

🔘 Currently taking ARV

Notes

__________________________________