Visit Details

Date

(a)

Type

(b)

Scheduled

Duration Since
(in months)

Start ART

(c)

Current Regimen

(d)

Weight (kg) / Blood Pressure

(e)

/

Height (cm)

(f)

BMI

(g)

Pregnancy

Status

(h)

Pregnant:
Outcome: Pregnant
Not pregnant
Abortion (AB)
Miscarriage (MC)
Live birth
Still birth

ANC No.

(i)

EDD:
Date of pregnancy end:

FP Status

FP/No FP

(j)

Method/Why

(k)

Tuberculosis Status

Status

(l)

Treatment No.

TBRx #

(m)

This is calculated from the TB enrolment form

Potential Side Effects

(n)

Other:

New OIs & Other Problems

(o)

Other , ,

WHO Stage

(p)

(age: )

Cotrimoxazole

Adherence

(q)

Dispensed

(r)

INH Dispensed

(s)

Other Medications Dispensed

(t)

Drug	Dose	Units	Frequency	Duration	Duration units

ARV Drugs

Adherence

(u)

Why poor/fair

(v)

Other:

Regm/Dose/Duration

(w)

Regimen and dose entered via ARV regimen editor

Duration Units:

Laboratory
Investigations
Done

CD4 (# or %)

(x)

Count: or %

Hgb

(y)

RPR

(z)

TB Sputum

(aa)

HIV Viral Load

(ab)

or

Other

(ac)

Add new result for

Referral / Hospitalized

(ad)

1.
2.
3.
Other:

Days hospitalized

At Risk Population

(ae)

PwP
Services
(✓)

Disclosure

Partner Tested

(af)

Condoms

Screened STI

(ag)

Date of Next Appointment

(ah)

Clinician Initials

(ai)