Dispensary Confirmation Form
Demographics
AMRS ID Number:
Family Name:
Given Name:
Middle Name:
Gender:
...
Male
Female
Date Of Birth:
Encounter Details
Name of Dispensary:
*
Screening Site:
*
...
Mosoriot Health Centre
Turbo Health Centre
Teso District Hospital
Chepsaita Dispensary
Angurai Health Centre
Changara Dispensary
Malaba Dispensary
Kamollo Dispensary
Mogoget Dispensary
Biribiriet Dispensary
Itigo Dispensary
Lelmokwo Dispensary
Kokwet Dispensary
Ngechek Dispensary
Cheramei Dispensary
Murgusi Dispensary
Cheplasgei Dispensary
Sigot Dispensary
Sugoi A Dispensary
Sugoi B Dispensary
Chepkemel Dispensary
Akichelesit Dispensary
Aboloi Dispensary
Moding Dispensary
Sambut
Ngenyilel
Sosiani
Provider ID:
David S. Pamba
Ariya Patrick
Benjamin Osiya Ekirapa
Molly Omodek Aluku
Mercyline Lubisya Omusolo
Julita Auma Ndege
Caroline Fedha Injete
Nelly Nabwire Shiundu
Nicholas Dekkers Shitaha
Tezra Asangire Okaal
Sophy Ikarot Idele
Maureen Jacinta Muteitsi
Gibson Musera Mutira
Titus Chuma Khusua
Pamela Ekuriai Emukule
Rhoda Jeruto Kurgat
Zaitun Hassan Mohamed
Grace Gichanga Nyathogora
Gabriel Silas Okapes
Henry Samson Obonyo
Rebecca M. Wambura
Zeruya Amwatok Barua
Immaculate Otengo Namibia
Pamela Were Wamoyi
Caroline Wafula Nandisi
Markins Opuko Cresent
Benedict Kifufuli Wafula
Clementine Ingosi Osiel
Enter provider's system-id:
*
Encounter Date:
*
Visit Type:
*
...
First Dispensary Visit After pHCT
Second Dispensary Visit After pHCT
Return Dispensary Visit
Referred from Clinic
WALK IN
Phone:
pHCT REVIEW
pHCT Encounter Date:
Systolic Blood Pressure from pHCT Screening card:
Diastolic Blood Pressure from pHCT Screening card:
Fasting Blood Sugar (FBS) from pHCT Screening card:
Random Blood Sugar (RBS) from pHCT Screening card:
Your current medications
Do you take any of the following medications?
Metformin
Glibenclamide
Enalapril
HCTZ
Losartan
Nifedipine
Amlodipine
Other Medications
None
If patient has been on
Enalapril
for over a year
Check creatinine and potasium
If patient has been on
Losartan
for over a year
Check creatinine and potasium
Metformin
Metformin dose in Milligrams (mg):
*
Metformin frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of scheduled [Metformin] you took:
*
...
All
More than half
Half
Less than half
None
Specify the reason for missing some of your [Metformin] doses:
*
...
No money
Facility stocked out of medication
Missed Appointment
Healed by faith
Forgot to take medicine
Medicine not useful
Side effects
Lack of Transport
Other
Glibenclamide
Glibenclamide dose in Milligrams (mg):
*
Glibenclamide frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of scheduled [Glibenclamide] you took:
*
...
All
More than half
Half
Less than half
None
Specify the reason for missing some of your [Glibenclamide] doses:
*
...
No money
Facility stocked out of medication
Missed Appointment
Healed by faith
Forgot to take medicine
Medicine not useful
Side effects
Lack of Transport
Other
Enalapril
Enalapril dose in Milligrams (mg):
*
Enalapril frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of scheduled [Enalapril] you took:
*
...
All
More than half
Half
Less than half
None
Specify the reason for missing some of your [Enalapril] doses:
*
...
No money
Facility stocked out of medication
Missed Appointment
Healed by faith
Forgot to take medicine
Medicine not useful
Side effects
Lack of Transport
Other
HCTZ
HCTZ dose in Milligrams (mg):
*
HCTZ frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of scheduled [HCTZ] you took:
*
...
All
More than half
Half
Less than half
None
Specify the reason for missing some of your [HCTZ] doses:
*
...
No money
Facility stocked out of medication
Missed Appointment
Healed by faith
Forgot to take medicine
Medicine not useful
Side effects
Lack of Transport
Other
Losartan
Losartan dose in Milligrams (mg):
*
Losartan frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of scheduled [Losartan] you took:
*
...
All
More than half
Half
Less than half
None
Specify the reason for missing some of your [Losartan] doses:
*
...
No money
Facility stocked out of medication
Missed Appointment
Healed by faith
Forgot to take medicine
Medicine not useful
Side effects
Lack of Transport
Other
Nifedipine
Nifedipine dose in Milligrams (mg):
*
Nifedipine frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of scheduled [Nifedipine] you took:
*
...
All
More than half
Half
Less than half
None
Specify the reason for missing some of your [Nifedipine] doses:
*
...
No money
Facility stocked out of medication
Missed Appointment
Healed by faith
Forgot to take medicine
Medicine not useful
Side effects
Lack of Transport
Other
Amlodipine
Amlodipine dose in Milligrams (mg):
*
Amlodipine frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of scheduled [Amlodipine] you took:
*
...
All
More than half
Half
Less than half
None
Specify the reason for missing some of your [Amlodipine] doses:
*
...
No money
Facility stocked out of medication
Missed Appointment
Healed by faith
Forgot to take medicine
Medicine not useful
Side effects
Lack of Transport
Other
Other Medication
Medication Name
Dose in Milligrams (mg):
Frequency per day:
...
Every Morning
Every Evening
Once Daily
Twice Daily
Dose in Milliliters (ml):
Symptoms
Do you have any of the following symptoms?
Leg Swelling (Oedema)
Shortness of breath with activity
Weakness in one part of the body
Reduced urine output
Heart Racing
Recurrent Dizziness
Fainting
Loss of consciousness
Vision Difficulties
Foot Complaints
Nausea
Vomiting
Abdominal Discomfort
Diarrhea
Constipation
Confusion
Convulsions
Recurrent Cough
Hunger, Sweating, dizziness and shaking
None of the above
Patient likely with complication in cardiovascular or neurological system
Call
0718980323
for input from consultant
Rule out TB
Change enalapril to losartan
Rule out TB
Others
How long ago was the first day of your menstrual period?
...
Less than 35 days ago
Over 35 days ago
Don't know
Systolic Blood Pressure (mmHg):
*
Diastolic Blood Pressure (mmHg):
*
Pulse Rate (per minute):
Temperature (centigrade):
Weight (KG):
Height (CM):
Body Mass Index:
confirmed overweight
Educate on weight reduction
Fasting Blood Sugar (FBS):
Random Blood Sugar (RBS):
Hemoglobin A1C:
Urine Pregnancy Test:
*
...
Positive
Negative
Indeterminate
Test Not Done
Educate on prevention
Weight reduction if BMI >25
Exercise
Smoking cessation
Alcohol reduction (if applicable)
DISCHARGE HOME
Pt under 35 with elevated BP
Refer to CO/Health Center
Hypertension in Pregnancy
.
REFER TO C.O/ High Risk ANC.
Advise on
Salt reduction
Weight reduction if BMI > 25
Exercise
Smoking cessation
Alcohol reduction (if applicable)
Review in a month
Stage II Hypertension
Refer to CO
START HCTZ 25mg Once daily
Give instructions on salt reduction
Review in a month
Confirmed Hypertension
Start HCTZ 25mg Once daily
Advise on
Salt reduction
Weight reduction if BMI > 25
Exercise
Smoking cessation
Alcohol reduction (if applicable)
Review in 3 months
Controlled Hypertension
Continue on HCTZ 25mg Once daily
Review in 3 months
Continue HCTZ 25mg a day
Add Amlodipine 2.5mg Once daily
Advise on
Salt reduction
Weight reduction if BMI > 25
Exercise
Smoking cessation
Alcohol reduction (if applicable)
Review in 3 months
Refer to CO if this is third dispensary visit on this drug regimen
Controlled Hypertension
Continue on HCTZ 25mg Once daily
Continue on Amlodipine 2.5mg Once daily
Review in 3 months
Continue HCTZ 25mg Once daily
Increase Amlodipine to 5mg Once daily
Advise on
Salt reduction
Weight reduction if BMI > 25
Exercise
Smoking cessation
Alcohol reduction (if applicable)
Review in a MONTH
Refer to CO if this is third dispensary visit on this drug regimen
Continue HCTZ 25mg Once daily
Continue Amlodipine 5mg Once daily
Review in 3 months
UNCONTROLLED HYPERTENSION
REFER TO CO
Advise on
Salt reduction
Weight reduction if BMI > 25
Exercise
Smoking cessation
Alcohol reduction (if applicable)
Request patient to come for fasting blood sugar
Patient does not have diabetes
Educate on prevention
Discharge
Followup after a year as needed
Patient with pre-diabetes
Educate on lifestyle modification
Repeat FBS after 6 months
Pregnant patient with Diabetes
Please Refer to High Risk ANC Clinic
Patient blood sugar is very high
REFER TO CO
Educate on lifestyle modification
DM CONFIRMED
Start on Metformin 500mg OD
To be seen in two (2) weeks
Possible Metformin side effects
Nausea
Vomiting
Abdominal pain
Diarrhea
constipation
Refer to CO
Patient's diabetes controlled with current regimen
Check HbA1C annually
Blood sugar not optimally controlled on metformin 500 mg twice daily
Increase Metformin up to 750mg twice daily (BD)
Follow up with patient after 2 weeks
Educate patient on lifestyle modification
Blood sugar not optimally controlled on metformin 500 mg twice daily
Increase Metformin up to 750mg twice daily (BD)
Follow up with patient after 2 weeks
Educate patient on lifestyle modification
Blood sugar not optimally controlled on metformin 750 mg twice daily
Titrate Metformin to 1000mg twice daily
Follow up with patient after 2 weeks
Educate patient on lifestyle modification
Diabetes not controlled with metformin 1000 mg twice daily
Refer client to Clinical Officer
Patient with severely elevated blood sugar and with current concern for complications
Refer to Clinical Officer
Patient with possible DM complications
Refer to Center of Excellence (COE)
Patient with Hypertension in Diabetes
REFER TO CO
Advice on salt reduction
Medications Prescribed
For Medications Prescribed, if there are different doses for the medication for different times of day, you should enter each as a separate prescription using the 'Add Group' feature.
Medications Prescribed:
Metformin
Glibenclamide
Enalapril
HCTZ
Losartan
Nifedipine
Amlodipine
Other Medications
None
Prescribed
Enalapril
Please confirm that client's creatinine is normal prior to starting Enalapril
If no creatinine is on record, please order creatinine
Prescribed
Losartan
Please confirm that client's creatinine is normal prior to starting Losartan
If no creatinine is on record, please order creatinine
Metformin Dispense
Did you change the [Metformin] dosage?
*
...
Yes
No
Do not know
Prescribed [Metformin] dose in milligrams (mg):
*
[Metformin] frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of [Metformin] tablets prescribed:
*
[Metformin] picked-up at dispensary?
*
...
Yes
No
Glibenclamide Dispense
Did you change the [Glibenclamide] dosage?
*
...
Yes
No
Do not know
Prescribed [Glibenclamide] dose in milligrams (mg):
*
[Glibenclamide] frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of [Glibenclamide] tablets prescribed:
*
[Glibenclamide] picked-up at dispensary?
*
...
Yes
No
Enalapril Dispense
Did you change the [Enalapril] dosage?
*
...
Yes
No
Do not know
Prescribed [Enalapril] dose in milligrams (mg):
*
[Enalapril] frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of [Enalapril] tablets prescribed:
*
[Enalapril] picked-up at dispensary?
*
...
Yes
No
HCTZ Dispense
Did you change the [HCTZ] dosage?
*
...
Yes
No
Do not know
Prescribed [HCTZ] dose in milligrams (mg):
*
[HCTZ] frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of [HCTZ] tablets prescribed:
*
[HCTZ] picked-up at dispensary?
*
...
Yes
No
Losartan Dispense
Did you change the [Losartan] dosage?
*
...
Yes
No
Do not know
Prescribed [Losartan] dose in milligrams (mg):
*
[Losartan] frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of [Losartan] tablets prescribed:
*
[Losartan] picked-up at dispensary?
*
...
Yes
No
Nifedipine Dispense
Did you change the [Nifedipine] dosage?
*
...
Yes
No
Do not know
Prescribed [Nifedipine] dose in milligrams (mg):
*
[Nifedipine] frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of [Nifedipine] tablets prescribed:
*
[Nifedipine] picked-up at dispensary?
*
>
...
Yes
No
Amlodipine Dispense
Did you change the [Amlodipine] dosage?
*
...
Yes
No
Do not know
Prescribed [Amlodipine] dose in milligrams (mg):
*
[Amlodipine] frequency per day:
*
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of [Amlodipine] tablets prescribed:
*
[Amlodipine] picked-up at dispensary?
*
>
...
Yes
No
Other Medication
Medication Name:
Medication dose in Milligrams (mg):
Medication frequency per day:
...
Every Morning
Every Evening
Once Daily
Twice Daily
Number of Medication tablets:
Education
Education Given:
Alcohol Reduction
General Diet Education
Diabetic Diet Education
Diabetic Danger Signs
Salt Reduction
Smoking Cessation
Exercise
Weight Reduction
Adherence Counseling
None
Referrals Ordered
Select all referrals made during this visit:
CO/Health Center
Return to Dispensary
ANC Clinic
High Risk ANC Clinic
None
General recommendation
1. If patient has diabetes and HbA1c observation date is more than 5 months
Advice patient to plan for upcoming HbA1c test in a month
2. If difference between last HbA1c date and current visit date is more than 6 months
Alert patient of a missed HbA1c test to be done immediately.
Return Date to Dispensary: