ARV Doctor Follow-up Free State H313 Pediatric HIV Care and Treatment Programme Print Form Treatment Site and Patient Information Date Encounter number Treatment Site Referring Assessment Site Date of Birth Patient's First Name Male Site File No. ID No. Barcode for Blood Tests Yes No Female Persal No. Type of Visit Planned: Unplanned: Routine follow-up Collect Medication Feeling unwell New problem Check blood results Check-up for recent problems Current Regimen Start Date ARV Start Date Current Antiretroviral Treatment 3TC (Lamivudine) ddI (Didanosine) D4T (Stavudine) ABC (Abacavir) EFV (Efavirenz) Ritonavir NVP (Nevirapine) Ritonavir/Lopnavir (Kaletra) AZT (Zidovudine) Other 1 Other 2 ARV Side Effects (Choose all that apply) Skin Rash Anaemia/pallor Gastrointestinal (nausea, vomiting, abd pains) Dry mouth Sedative effects/sleepiness Pruritis Diarrhea Nausea and vomiting Peripheral neuropathy/weakness Headache Muscle pain/muscle weakness Confusion Other None www.fs.gov.za Comment to Adherence (Choose all that apply) Opportunistic Infection Prophylaxis: Fluconazole Cotrimoxazole TB Status Dapsone INH None of These (choose one) If yes, months On TB Treatment---------TB Symptoms Was Sputum sent? Yes No No TB Treatment & no symptoms Weight kg Hospitalisation since last visit No Prophylaxis Discontinued Yes if yes how many times? Sputum 1 pos neg Sputum 2 Height cm BSA m2 Reason(s): 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 Treatment Failure Other OI Prophylaxis Any changes? No Yes Cotrimoxazole 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 Investigation Done: Investigation: Results: Date: CD4 Mantoux Sputum for AFB FBC/Hb Triglycerides Random Glucose ALT Viral load Random Cholesterol CXR U and E Follow-up Appointments Date of Next Assessment Site appointment Date of Next Treatment Site appointment Medication (Other than ARVs and OI prophylaxis) Encounter Created by Date Captured: Data Captured by: www.fs.gov.za