Form Id: FRM_HIVGREEN_KE
ENGLISH FRANÇAIS PORTUGUÊS ITALIANOVisit Type | |
| Visit Scheduled ?: | |
| Visit By:: | |
Population | |
| Population Type: | |
If you have selected "Key Population" choose from the following: | |
| People who inject drugs: | |
| Transgender: | |
| Female sex worker: | |
| People in prison and other closed settings: | |
| Men who have Sex with Men(MSM): | |
If you have selected "Priority Population" choose from the following: | |
| Fisher folk: | |
| Truck driver: | |
| Adolescent and young girls: | |
| Prisoner: | |
| Not applicable: | |
Sexual and Reproductive History | |
| Has patient ever had menses?: | |
| When was your LMP Date ?: | |
| Menopause: | |
| Patient Pregnant?: | |
| Wants to get pregnant in three months?: | |
| Patient Breastfeeding?: | |
| ANC Number: | |
| EDD: | |
| ANC/PNC Profile: | |
| Parity (gestational age of 24 weeks or more): | |
| Parity + (miscarriages or terminations): | |
| Gravida: | |
PHDP Services | |
| Has the Client disclosed HIV status to their sexually active partner?: | |
| STI Partner Notification: | |
| Has the client's partner received on-site HIV testing?: | |
- | |
| PHDP Services offered ?: | |
| Family Planning Status: | |
If currently using Family Planning or wants F.P. .. specify: | |
| Emergency contraceptive pills: | |
| Oral Contraceptives Pills: | |
| Injectible: | |
| Implant: | |
| Intrauterine Device: | |
| Lactational Amenorhea Method: | |
| Diaphram/Cervical Cap: | |
| Fertility Awareness: | |
| Tubal Ligation: | |
| Condoms: | |
| Vasectomy(Partner): | |
Not using Family Planning? Specify | |
| Thinks can't get pregnant: | |
| Not sexually active now: | |
| Other: | |
ARV Adherence Assessment | |
| 1. Do you ever forget to take your medicine?: | |
| 2. Are you careless at times about taking your medicine?: | |
| 3. Sometimes if you feel worse when you take the medicine, do you stop taking it?: | |
| 4. When you feel better do you sometimes stop taking your medicine?: | |
| 5. Did you take the medicine yesterday?: | |
| 6. When you feel like your symptoms are under control, do you sometimes stop taking your medicine?: | |
| 7. Do you ever feel under pressure about sticking to your treatment plan?: | |
| 8. How often do you have difficulty remembering to take all your medications?: | |
| Adherence Score: | RESULT: SCORE |
| Adherence rating: (automatic evaluation not working in preview) | |
Establishment assessment / Differentiated Care | |
| Healthcare team is satisfied about providing longer follow-up intervals for the patient?: | |
| Differentiated care: | |
| Willing to receive reminders/notifications about the appointments?: | |
| Medical insurance cover: | |
Note: Any gray lines, in production, will be enabled under pre-set conditions, but this functionality does not work in this preview
