ARV Nurse Follow-up Free State H309 Print Form Pediatric HIV Care and Treatment Programme Assessment Site and Patient Information Date Encounter number Assessment Site Date of Birth Patient's First Name Male Site File No. ID No. Yes Barcode for Blood Tests No Female Persal No. Type of Visit Planned: Unplanned: Routine follow-up Collect Medication Yes No Feeling unwell New problem Yes No Check blood results Check-up for recent problems If Medication was collected: Medication collected by patient Yes No Medication Collected by Relation to patient Reason for collecting Number of months issued today Current Regimen Start Date ARV Start Date Current Antiretroviral Treatment (Choose) 3TC (Lamivudine) ddI (Didanosine) D4T (Stavudine) ABC (Abacavir) EFV (Efavirenz) Ritonavir NVP (Nevirapine) Ritonavir/Lopnavir (Kaletra) AZT (Zidovudine) Other 1 Other 2 Weight kg Height cm BSA m2 www.fs.gov.za ARV Side Effects (Choose all that apply) Skin Rash Anaemia/pallor Gastrointestinal (nausea, vomiting, abd pains) Dry mouth Sedative effects/sleepiness Pruritis Diarrheoa Nausea and vomiting Peripheral neuropathy/weakness Headache Muscle pain/muscle weakness Confusion Other None Comment to Adherence Good Adhere (Missed no Doses) Missed a few doses Missed many doses (Choose all that apply) Opportunistic Infection Prophylaxis: Fluconazole Cotrimoxazole Dapsone INH 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 Mantoux Done? Hospitalisation since last visit No Yes if yes how many times? pos neg Yes Reason(s): Mantoux pos neg No Hospitalisation 1 Date Duration (nights) Hospitalisation 2 Date Duration (nights) Plan ARV Treatment: No Any changes? Yes If yes, give new treatment combination below: 3TC (Lamivudine) ddI (Didanosine) D4T (Stavudine) ABC (Abacavir) EFV (Efavirenz) Ritonavir NVP (Nevirapine) Ritonavir/Lopnavir (Kaletra) AZT (Zidovudine) Other 1 Other 2 Reason for change: Drug Intolerance/Toxicity OI Prophylaxis Any changes? No Yes Cotrimoxazole Treatment Failure Other If yes, give new prophylaxis below: Fluconazole Dapsone INH Prophylaxis Discontinued Reason for change: Drug Intolerance/Toxicity Sustained CD4 > 200 Other www.fs.gov.za Follow-up Appointments Date of Next Assessment Site appointment Date of Next Treatment Site appointment Supplements Issued No Yes Medication (Other than ARVs and OI prophylaxis) Encounter Created by Date Captured: Data Captured by: www.fs.gov.za