ART MEDICAL VISIT

Patient Surname: ______First Name:______Age: ______IR19P:______

Scheduled Visit [ ] Yes [ ] No

Vital Signs / ART Adherence / Counseling Notes
Wt:______Kg Ht:______
Temp:_____C
HR: ______BPM
BP: ____/____ mmHg
Pain: 0=no pain 6=worst pain
0 1 2 3 4 5 6
Location:
Duration:

Functional status

o  Work
o  Ambulatory
o  Bedridden

Nutrition status Adults

o  Under weight: ≤18.5
o  Normal wt: 18.5-24.9
o  Over weight:25-29.9
o  Obesity: ≥ 30
Septrin Adherence
Pill count done [ ] Yes [ ] No
%age of adherence______

Assessment for Family Planning

o  Condoms
o  Oral Contraceptive pills
o  Injectable /Implantable hormones
o  Diaphram /Cervical Cap
o  Intra uterine device(IUD)
o  Vasectomy/tubal ligation / hysterectomy
o  Natural methods
o  NA / Date client started ART:______
Length of Time on ART:______
[ ] ART regiment: (circle) 1st line 2nd line
[ ] Pill count done: %age of adherence:______
G (good) >95% P (poor) <85%
F (fair) 85-94%
[ ]ART stopped Date Stopped------/------/------
Reasons for stopping
______
Assessment for TB
Fever for >2weeks Y[ ] N [ ];
Night Sweats Y [ ] N [ ]
Cough for >2weeks Y [ ] N [ ];
Weight loss Y[ ] N [ ]
Low appetite Y [ ] N [ ]
Cough with Blood Y [ ] N [ ]
( If Yes refer for sputum examination immediately)
TB SUSPECT Y [ ] N [ ]
No evidence of TB
TB case Y [ ] N [ ] If Yes, duration on treatment______

Assessment for Family Planning

1.  Do you have a sexual partner [ ] Yes [ ] No
2.  Have you disclosed [ ] Yes [ ] No
3.  Are you on family planning [ ] Yes [ ] No
4.  Do you have plans on getting another baby [ ] yes [ ] No
o  LNMP__/___/____ [ ] Menopause [ ]NA
Nurse’s Name :______ / Assessment for STIs
Does the patient have history suggestive of STI Y[ ] N [ ]
If yes,
[ ] Genital Ulcer [ ] Genital growth
[ ] Genital discharge [ ] Genital swelling
[ ] Genital pain [ ] Genital itching
[ ] Genital pain with micturation
[ ] Others (specify): ………………………..
On –going adherence counseling
Review and assess adherence over the last month
Review the treatment regimen
o  Medicines dosing
o  Dietary instructions
o  Storage
o  Disclosure
Discuss adherence
o  Taken all doses
o  Taken on time
o  Reasons for missing
o  Complete pill count and self report
o  Inquire about any proposed travel
o  Change of address and review contact information
o  Any barrier to adherence
No. of children <15 years
No. tested:______
No. Positive:______
Counselor’s Name:______
Symptoms/Lab Results / Clinical Findings / Exam
[ ] Weight change: ______
Last CD4 count: ______
Date done:______
Next CD4 count due: ______
WHO Stage: I II III IV
WHO Stage changed? [ Y] [ N]
If yes, from ____ to ______
Why?______
[ ] ARV regiment changed: date __/__/___
Changed from ______to ______
Reason for change: ______
______
[ ] On TB therapy?

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Diagnosis/Problems:

[ ] No Problem

[ ] Zoster

[ ] Pneumonia

[ ] DEmentia/Enceph

[ ] Thrush-oral/virginal

[ ] COUGH

[ ] FEVER

[ ] DB difficulty in breathing

[ ] Weight loss

[ ] UD urethral discharge

[ ] PID pelvic inflammatory disease

[ ] Ulcers-mouth or other ______

[ ] GUD genital ulcer disease

[ ] IRIS Immune reconstitution inflammatory syndrome

[ ] Other specify______

Clinician Name:______

Treatment

No. / Drug / Dosing / Duration
1
2
3
4
5
6

Return Date: ____/______/______

1