-Clinic identification number
|
-Patient identification number
|
-Patient identification number
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-Date of visit
|
-Date of enrollment at HIV clinic
|
-Type of provider seen
|
-Pregnancy status at time of enrollment
|
-Pregnant at time of visit
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-Number of months pregnant at enrollment
|
-Temperature
|
-Age
|
-Weight
|
-Gender
|
-Height
|
-Site of HIV testing
|
-CD4 count
|
-Date of HIV testing
|
-CD4 percentage
|
-Results of HIV testing
|
-Date of CD4 count
|
-City of residence
|
-Viral load
|
-Neighborhood of residence
|
-Date of viral load
|
-Marital status
|
-Clinical diagnoses*
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-Type of employment
|
-WHO stage
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-Years of education
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-CTX prophylaxis
|
-Type of higher education
|
-TB prophylaxis
|
-Patient active at HIV clinic (yes/no)
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-Patient receiving ART
|
-Reason patient left HIV clinic
|
-Type of ART regimen
|
-Date patient left HIV clinic
|
-Type of ART refill visit
|
-Date the HIV clinic found out patient left
|
-# of pills dispensed
|
-Exit comments
|
-Next refill date
|
-ART committee date
|
-Receiving TB treatment
|
-Patient receiving ART (yes/no)
|
-Comments
|
-ART start date
| |
-Type of ART initiation (new patient or transferred from another facility)
| |
-Comments about treatment
| |
-Pregnancy status at time of treatment initiation
| |
-Prophylaxis for PMTCT
| |
-Prophylaxis type
| |
-Prophylaxis date
| |