ARV Nurse Follow-up Free State H309 Print Form Adult HIV Care and Treatment Programme Assessment Site and Patient Information Date Encounter number Assessment Site Date of Birth Patient's Full Name Male Site File No. ID No. Barcode for Blood Tests Yes No Female Persal No. Type of Visit (Choose all that apply) Collect Medication Check-up Visit for Recent Problem Routine Follow-up Visit Umplanned Visit (feeling unwell/ new problem) If Medication was collected: Medication collected by patient Yes No Medication Collected by Relation to patient Reason for collecting Number of months issued today ARV Start Date Current Antiretroviral Treatment 3TC (Lamivudine) EFV (Efavirenz) AZT (Zidovudine) LPV/r (400/100mg) D4T (Stavudine) NVP (Nevirapine) ddI (Didanosine) LPV/r (400/400mg) Other 1 Other 2 ARV Side Effects and Adherence Skin Rash (Choose all that apply) Gastrointestinal Burning/Numbness in Hands/Feet None Other ARV Adherence (Choose one) Good adherence (Missed no doses) Missed a few doses Misses many doses If poor adherence, why? (choose all that apply) Side effects Clinic ran out of medicine Social Reasons Give details www.fs.gov.za (Choose all that apply) Opportunistic Infection Prophylaxis: Cotrimoxazole Fluconazole INH Dapsone Prophylaxis Discontinued None of These TB Status On TB Treatment---------- If yes, months TB Symptoms-------------- If yes, was sputum sent? Yes No -------- If yes... Sputum 1 No TB Treatment & no symptoms Sputum 2 Weight Previously Weight Today kg Family Planning (Woman Only) pos neg kg (Choose all that apply) Injectable Birth Control pills Other Hysterectomy Pregnant Previous Sterilisation Refuse Post Menopausal Family Planning Condoms None (Men Only) Vasectomy None Follow-up Appointments Date of Next Assessment Site appointment Date of Next Treatment Site appointment (if applicable) DateTreatment Commenced Supplements Issued Encounter Create by Yes No Date Captured: Data Captured by: www.fs.gov.za