HIV Family History
Demographics
OpenMRS ID:
Family Name:
Given Name:
Middle Name:
Gender:
...
Male
Female
Date Of Birth:
Name of family member:
*
Age at diagnosis:
*
Will record Age in ...
*
...
Years
Months
Age(Years):
*
Age(Months):
*
Relation:
*
...
Mother
Father
Grandmother
Grandfather
Sibling
Child
Aunt
Aunt
Partner or Spouse
Co-wife
Guardian
Other Non-Coded
HIV Result:
*
...
P
N
E
DK
In Care?:
...
Yes
No
Unknown
CCC Number:
*
Encounter Date
*
Encounter Location:
*
Encounter Location
*
...
Provider Name:
*
Provider's system-id:
*