ARV Baseline Assessment (Doctor) Free State H314 Adult 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 Yes Barcode for Blood Tests Female Male Site File No. ID No. No Persal No. HIV History HIV first diagnosed Previous ARV Exposure: Transfer in OR From where Private None (If yes, complete) Other PMTCT AZT Appropriate (triple therapy/continuous/uniterrupted)? Inappropriate (mono- or dual therapy/intermittend/sporadic)? PMTCT Nevirapine Indicate previous ARV's taken: DURATION DRUG DRUG DURATION DURATION DRUG 3TC (Lamivudine) (months) NVP (Nevirapine) (months) LPV/r (400/400mg) (months) D4T (Stavudine) (months) AZT (Zidovudine) (months) LPV/r (400/100mg) (months) EFV (Efavirenz) (months) ddI (Didanosine) (months) Other 1 (months) Other 2 (months) Pre-treatment CD4 known? Yes No Opportunistic Infection Prophylaxis: Cotrimoxazole Fluconazole If yes, give value (Choose all that apply) INH Dapsone Yes if yes how many times? Prophylaxis Discontinued None of These Admin Date Hospitalisation in last 6 months: Reason(s): No cells/ul Date Hospitalisation 1 Date Duration (nights) Hospitalisation 2 Date Duration (nights) Hospitalisation 3 Date Duration (nights) Pre-treatment CD4 result (cells/ul) Date www.fs.gov.za WHO Staging System Who Stage 4: Who Stage 3: Who Stage 1: Unexplained Prolonged Fever Candida (esoph, bronchi, trachea) (or lung) Cryptococcosis - Extrapulmonary Cryptosporidiosis with Diarrhoea (> 1 month) CMV Oral Hairy Leukoplakia Herpes Simplex TB Pulmonary (within last year) Karposi's Sarcoma HIV Wasting Syndrome HIV Encephalopathy Asymptomatic HIV Infection Severe Bacterial Infection Persistent Generalised Lymphadenopathy Oral Candidasis (thrush) Unexplained Chronic Diarrhoea (> 1 month) Who Stage 2: Herpes Zoster (within 5 years) Minor Mucocutaneous Manifestations Recurrent Upper Respiratory Tract Infection Weight Loss >=10% Body Weight Weight Loss <10% Body Weight Performance Scale 3 Atypical Mycobacteriosis, Disseminated Mycosis, Disseminated Tuberculosis - Extrapulmonary PCP PML Salmonella Septicemia - Non-typhoid Toxoplasmosis - CNS Lymphoma Recurrent Pneumonia TB History Previous TB Yes If Yes, how many times treated? No Invasive Ca Cervix Treatment 1 (months) Performance Scale 4 Treatment 2 (months) TB Status On TB Treatment---------- If yes, months TB Symptoms-------------- If yes, was sputum sent? Yes No -------- No TB Treatment & no symptoms Family Planning Previous sterilization No pos neg Sputum 2 (Woman Only) Yes If yes... Sputum 1 pos neg If no -- Pregnancy test Contraception (choose all that apply) Injectable Post Menopausal Previous Sterilisation Pregnant Birth control pills Other Refuse Hysterectomy Family Planning Condoms None (Men Only) Vasectomy None Physical Examination Temperature oC Blood Pressure mmHg Weight kg Features peripheral neuropathy Pulse rate (beats/min) Yes beats/min No -------www.fs.gov.za Karnofsky Index 100% Normal, no complaints, no evidence of disease 90% Able to carry out normal activity, minor signs or symptoms of desease 80% Normal activity with effort, some sign or symptoms of disease 70% Care for self, unable to carry on normal activity or do active work 60% Requires occasional assistance but is able to care for most of her/her needs 50% Requires considerable assistance and frequent medical care 40% Disabled, requires special care and assistance 30% Severely disabled, hospitalization is indicated although death not imminent 20% Very sick, hospitalization necessary, active support treatment necessary 10% Moribund, fatal processes progressing rapidly Plan Investigations ARV Treatment: Delay ARV's Start Drug Readiness Training Start ARV's Delay ARV's: Give reasons (Choose all that apply) Acute TB < 2 nonths treatment TB not yet excluded Acute Illness ---------- give details Other ------------- give details Date Treatment Commenced Date Captured: Encounter Created by: Data Captured by: Doctor's Notes Name Sign www.fs.gov.za