CDM CHW Form v 0.01

Demographics

AMRS ID Number:

Family Name:

Given Name:

Middle Name:

Gender:

Date Of Birth:

Encounter Date:*

Previous date this form was filled:

Missed appointment date:

PHCT Blood Sugar Readings

Random blood sugar (RBS):

mmol/L

Fasting blood sugar (FBS):

mmol/L

PHCT Blood Pressure Readings

Systolic blood pressure:

mmHg

Diastolic blood pressure:

mmHg

Name of facility client was referred to:

Date referred:

Client referred from:*

PHCT

MCH

Clinic

Other

Specify*

Type of CHW follow up:*

Hypertension

Diabetic

Other

Specify*

Reason for follow up:*

Not linked to care

Lost to follow up

Other

Specify*

Reason for missed appointment:*

Lack of time

Lack of money

Lack of confidence in health care worker(s)

Lack of transport

No symptoms of illness

Visited not seen

Visited dispensary closed

Distance (too far)

Sought care elsewhere

Other

Specify*

Are you currently on any treatment/ medication?*

Yes

No

Are you enrolled to care in another facility?*

Yes

No

Referred to?*

Date:*

Planned CHW follow up date?*

Provider Name:

Enter provider's system-id:*