ARV Doctor Follow-up Free State H313 Print Form Adult HIV Care and Treatment Programme Treatment Site and Patient Information Date Encounter number Treatment Site Referring Assessment Site Date of Birth Patient's Full Name Male Site File No. ID No. Yes Barcode for Blood Tests No Persal No. Yes Booked follow-up appointment Female No 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 Start Date Current Regimen Start Date: (if different) ARV Side Effects and Adherence Skin Rash (Choose all that apply) Gastrointestinal (nausea, vomiting, abd pains) Burning/ Numbness in Hands/ feet None Other Comment to Adherence Opportunistic Infection Prophylaxis: Cotrimoxazole Fluconazole (Choose all that apply) INH Dapsone Prophylaxis Discontinued None of These TB Status On TB Treatment---------- If yes, months TB Symptoms-------------- If yes, was sputum sent? No TB Treatment & no symptoms Weight Today kg Weight Previously Yes No -------- If yes... Sputum 1 pos neg Sputum 2 kg www.fs.gov.za Family Planning (Woman Only) (Choose all that apply) Injectable Birth Control pills Other Post Menopausal Pregnant Previous Sterilisation Refuse None Family Planning (Men Only) Vasectomy Condoms None Reason(s): Hospitalisation since last visit No Hysterectomy Yes if yes how many times? Hospitalisation 1 Date Duration (nights) Hospitalisation 2 Date Duration (nights) Investigation Investigation: Results: CD4 cells/ul Viral Load copies/ml ALT(if on AZT) Hb(if on AZT) u/l g/dl Fasting Glucose (if on LPV/r) mmol/l Fasting Cholesterol (if on LPV/r) mmol/l Tryglycerides (if on LPV/r) mmol/l RPR Sputum (AFB) pos neg Sputum 1 Sputum 2 Plan ARV Treatment: Any changes? No Yes If yes, give new treatment combination below: 3TC (Lamivudine) EFV (Efavirenz) AZT (Zidovudine) LPV/r (400/100mg) D4T (Stavudine) NVP (Nevirapine) ddI (Didanosine) LPV/r (400/400mg) Other 1 Other 2 Reason for change: Drug Intolerance/Toxicity Treatment Failure Pregnancy Other OI Prophylaxis Any changes? No Yes Cotrimoxazole If yes, give new prophylaxis below: Fluconazole Prophylaxis Discontinued Dapsone INH Reason for change: Drug Intolerance/Toxicity Sustained CD4 > 200 Pregnancy Other www.fs.gov.za Follow-up Appointments Date of Next Assessment Site appointment Date of Next Treatment Site appointment Medication (Other than ARVs and OI prophylaxis) Date Treatment Commenced Doctor's Notes Name Encounter Created by Sign Date Captured: Data Captured by: www.fs.gov.za