Pregnancy Sample Paper Work – Fill Out and Use

PPCT POSITIVE IN PREGNANCY FORM

DATE:_____/______/_____

DD

MM

YYYY

NAME:

PSC Patient ID:

ANTENATAL ID:

SITE:

Date of Birth: _____/____/_____

DD

MM

YYYY

If birth date unknown, age at last birth day: ____ years

SOCIAL/DEMOGRAPHIC HISTORY:

Date of 1st positive HIV test:

฀ Yes

฀ No ฀ N/A

______/______/_________

Has your partner been tested for HIV?

DD

MM

YYYY

What is your occupation?

Do you (or your family) generally have enough money to cover your expenses?

___________________________

฀ Yes

฀No

What is your marital status?

Highest level of education

How many people usually live in your household

฀ Single

฀ None

including yourself? _______

฀ Widowed/single

฀ Some primary

Children under 5 years of age? ______

฀Widowed/married

฀ Some secondary

Children between 5 and 14 years of age______

Individuals that are 15 years of age

฀ Married/living together

฀ Some college/university

or older? ________

male, number of wives_______

female, number of co-wives_____

DISCLOSURE

Have you disclosed your HIV status to anyone?

฀ Yes

฀No

To whom?

฀ Partner/spouse

฀Friend

฀Relative

฀ Other (specify): ______________________

OBSTETRIC HISTORY

Enter number of:

Total pregnancies ______

Live births ____________

LMP _______/_______/_________

EDD: _______/_______/_______

Miscarriages___________

DD

MM

YYYY

DD

MM

YYYY

Currently living_________

How many months are you

REFER TO MOH MOTHERS HEALTH CARD

(if none-> mark 0)

currently pregnant? ________

FOR ANATENAL CARE

PAST MEDICAL AND SURGICAL HISTORY

฀ Diabetes

฀Hypertension ฀PreEclampsia/Toxemia

฀Cesarean ฀4th degree Laceration/fistula

Has the patient been treated for TB before?

฀Yes

฀No

If yes, year_______

TB HISTORY

Is the patient currently being treated for TB?

฀Yes

฀No

Any household member previously/currently treated for TB?

฀Yes

฀No

PHYSICAL EXAMINATION

VITALS

EXAMINATION

COMMENTS/DESCRIPTION

Eyes, Ears, Nose, Throat

Temp: ______ o C

Lymph Nodes

Pulse:

______ b/min

Respiratory

Cardiovascular

BP:

___/___ mmHg

Gastrointestinal

Weight:______Kg

Neurological

Height: ______cm

Musculoskeletal

Resp. rate:__________

Genitourinary

breaths/min

Skin

Other

□ Asymptomatic HIV Infection

□ Persistent Generalized Lymphadenopathy (PGL)

□

Moderate weight loss (<10% of presumed or measured body

□

Herpes Zoster past or recurrent within last 2 years

□

weight)

□

Recurrent or chronic upper respiratory tract infections

Minor mucocutaneous manifestations (seborrheic dermatitis,

(bacterial sinusitis, bronchitis, otitis media pharyngitis)

prurigo, fungal infection, recurrent oral ulcerations, angular

cheilitis

□

Severe weight loss (> 10% of presumed or measured body weight)

□ Oral hairy leukoplakia (OHL)

□ Unexplained chronic diarrhea > 1 month

□

Pulmonary tuberculosis (PTB) in last year

□ Unexplained prolonged fever > 1 month

□

Severe bacterial infections (e.g. pneumonia,

□

Oral candidiasis (Thrush)

pyomyositis, empyema, bone or joints infections)

□ HIV wasting syndrome (Severe weight loss and either unexplained

□

Isosporiasis

□

chronic diarrhea or unexplained prolonged fever > 1 month)

□

Disseminated non-tuberculous mycobacterial

Pneumocystis carinii pneumonia

infection

□ Recurrent severe bacterial pneumonia (>/=2 episodes within 1

□

Cytomegalovirus (CMV) retinitis or disease of the

year)

□

Progressive multifocal leukoencephalopathy (PML)

□

Cryptococcal meningitis, cryptococcosis

□

Any disseminated endemic mycosis (e.g.

□ Toxoplasmosis of the brain

histoplasmosis)

□ Chronic orolabial, genital or ano-rectal herpes simplex virus

□

Candidiasis of the oesophagus or airways

infection > 1 month

□

Non-typhoid salmonella (NTS) septicaemia

□

Kaposi’s sarcoma

□

Primary CNS lymphoma or B cell NHL

□

HIV encephalopathy

□ Extra pulmonary tuberculosis (EPTB)

□ Cryptosporidiosis with diarrhea > 1 month

Based on history and physical examination, indicate the most advanced WHO stage: O 1

O 2

O 3

O 4

INVESTIGATIONS ORDERED TODAY

฀ HB

฀UA

฀Blood group/RH

฀MPS

฀ VDRL

฀ CD4

MEDICATIONS PRESCRIBED TODAY

ARVS: ฀NVP ฀AZT

฀Other ARVS ______, ______, ______, ______

O Multivitamin

O CTX

O Food by prescription

O Iron/folate

O Albendazole

O Anti TB medications ______,

______,

O TT

O Malaria IPT

______, _______

WHAT REFERRALS WILL BE MADE FOR THE PATIENT?

฀None

฀TB treatment/DOT program

฀ PSC for HIV care

฀Social Support groups

฀Nutritional services

฀Inpatient care/Hospitalization

฀Other referral, specify:________________

Follow up issues for next visit:

Form completed by:

Next Scheduled Appointment Date

CCHA______________________________

______ / ______ / ________

Nurse

________

DD

MM

YYYY

Clinical Officer

Medical Officer