HIV Care/ ART clinic Intake form- A Socio demographics & family care FEDERAL MINISTRY OF ALTH OF ETHIOPIA

Facility Name_________________ MRN ________ Enrollment date: ___/___/____(DD/MM/YY) Unique ART No. _______ Unit TB No. ______

Client Name________________________Fathers’Name_________________________Garand Fathers’ ___________________________

For child only:- Mother’s Name: __________________________ Place of delivery: O Health facility O Home O Other specify _________
Mode of delivery O Spontaneous vaginal O Cesarean section O Other specify __________
Date of birth ______/______/_____ age: ______years (enter months for a child<5 years of age ) Sex: O M O F
Client/ child’s care giver) Marital Status: O Never Married O Married O Divorced O Widowed
Religion: O Orthodox O Muslim O Protestant O Catholic O Other______________
Level of education: O No education O Primary O Secondary O Tertiary O Other/specify_____________ Occupation: _____________
Address: Region___________ Zone/Sub city_______________ Woreda_____________ Kebele _________ House No.________ Telephone ________________
Client reside within the catchments area O Yes O No , if no; Is challenge anticipated to regularly follow in this facility O Yes
O No
Date confirmed HIV+: ______/_____/__________(DD/MM/YY) Type of HIV Test: O Rapid HIV tests O DBS/PCR (for children)

CLIENT REFERRAL INFORMATION

From with-in the Facility

O Medical OPD O Pediatric OPD O TB Clinic O MCH (PMTCT) O VCT O Adult IPD
O Pediatric IPD O Other Outpatient specify_________________
Outside the Facility
O Health Centers O Public Hospital O Private Hospital O NGO/FBO Hospital O Private Clinic O Self-referred O Others ___________

CARE GIVER/EMERGENCY CONTACT INFORMATION

Full Name: ____________________________________ Age: _____Gender: O Male O Female Relation: ______________________

Address: Region________ Zone/Sub city____________ Woreda_____________ Kebele _________ House No.________ Telephone ________________
DISCLOSURE AT ENROLLMENT:
Does anyone else know about your/your child’s HIV Status? O Yes ONo
If yes who knows your/your child’s HIV positive status? O Spouse (Wife/Husband) O Own Child (ren) O Parent(s)
O Sibling(s) (Brother(s)/Sister(s) O Relatives O Friends O Others ___________________________
FAMILY MEMBERS(Spouse/Parent and Child/ren/Sibling) HIV STATUS AT ENROLLMENT AND FOLLOW UP Visit
(Enter date for appropriate HIV status in DD/MM/YY format*)

At enrollment At enrollment or follow up visit: update all black fields as status

changed
Family member Age Sex Health status (healthy, Counseled Tested HIV test Enrolled Started Unique
chronically ill, dead for HIV* for HIV* Result; NR, R in Care* ART * ART #
*
Spouse/Parent
Child1/Sibling
Child2/Sibling
Child3/Sibling
 INTAKE-ART 2017
INSTRUCTIONS: Intake form- A Socio demographics & family care
Note: All but family HIV status fields must be completed at enrollment & all date fields must use Ethiopian calendar in DD/MM/YY
format
Health Facility Name – Health Facility name as registered at the Ministry of Health
Medical Record Number (MRN): Unique individual identifier on medical information provided by facility on folder
Enrollment date: Enter the date client was registered in HIV care using Ethiopian calendar in DD/MM/YY format
Unique ART number: Unique identifier assigned to a client when stating ART. It is composed of region number/ facility type code/ specific facility code
/client assigned 5 digit serial numbers starting as 00001
Region Code: [Link] (TG) ) [Link] (AF) [Link] (AM) 4. Oromia (OR) 5. Somali (SO)
6. Benshangul Gumuz (BG) 7. SNNPR (SN) 12. Gambella (GA) 13. Harar (HA) 14. Addis Ababa (AA) 15. Dire
Dawa (DD)
Facility Type code: Use 08 for Hospital and 09 for Health center
Client Name: Enter client’s given name, Father’s Name: - Enter client’s father’s name. If not known enter NA Grandfather’s Name: - Enter client’s
grandfather’s name. If not known enter NA
For a Child ask and fill Mother name, place and mode of delivery as:
Child’s; mother Name: Enter client’s mother if the client is a child <15 years. If clients mother name is not known enter NA
Place and mode of delivery: Mark in appropriate circle that indicate the place and mode of child’s delivery
Date of Birth: - Use Ethiopian calendar in DD/MM/YYYY format. If only month & year are known, enter 00 for day, if only year is known, enter 00 for day & 00
for month
Age: - Enter Client’s current age in years. If Client is less than 5 years old, enter age in months.
Sex: -Mark in the appropriate circle that indicate sex of the client
Marital Status: - Mark in appropriate circle that indicate clients (child’s care giver) current marital status
Religion: - Mark in appropriate circle that indicate religion of the client
Level of Education: - Mark in appropriate circle that indicate client’s completed year of schooling
Occupation: Enter what the client’s current works for living
Client Address: - Enter the current permanent address of the client including; Region, Zone/Sub-city, Wereda , Kebele , House number as
well as telephone number
For clients out of the catchment area of this facility: confirm absence of barriers for regular follow up at this facility including, time,
transport access, transport money
Date confirmed HIV+: Enter test date using Ethiopian calendar in DD/MM/YYYY format; if tested more than once, enter the most recent one
Type of HIV Test Mark in appropriate circle that indicate the type of test the client took
Client referral information; Mark in appropriate testing point if client linked from with the facility or indicate facility type if from outside facility
Care giver information: Enter the name, the address & relationship of care giver; to avoid unintended disclosure it is advisable if care giver
is confided client sero-status
Disclosure at enrollment: Does anyone know client HIV Status? Mark appropriate response that indicate clients disclosure status
To who knows clients HIV status: Mark appropriate response that indicate for whom the clients has disclosed
Family members (spouse/parent /child/ren/sibling’s)
HIV status: at enrolment Mark the relationship, enter the age, sex & health status of client’s each family members and for those whose HIV
Status is determined indicate the date
 At follow up visits: if the status of the clients family member changed enter the date in DD/MM/YY format in the cell corresponding to the
updated status

HIV Care/ ART clinic Intake form-B Past, presenting illness & PHDP FEDERAL MINISTRY OF ALTH OF ETHIOPIA
Facility Name_________________ MRN ___________
PAST OPPORTUNISTIC ILLNESS (OI), PRPHYLAIS AND TREATMENT (MARK ALL THAT APPLY)
Past OI
O Pulmonary TB O TB-Extrapulmonary O Fever (>1 month; unexplained) O Diarrhea (>1 month) O Oral Candidiasis
O pharyngeal candidiasis O Wasting Syndrome O Pneumocystis Carinii Pneumonia O Pneumonia (recurrent) O Cryptococal Meningitis
O Minor Mucocutaneous manifestations O Herpes-simplex(>1month) O Toxoplasmosis (brain) O Kaposi sarcoma O Other specify_______________________
Past Prophylaxis/Treatment
Cotrimoxazole: Date started _____/______/_____ If stopped; date stopped ____/______/_____
INH: Date started _____/______/______ If completed; date completed ____/______/_____
ARV For PMTCT:- O Yes O No If Yes Health facility:-___________Regimen for mother:______ Regimen for baby: ___________
Lifelong ART/TI:- O Yes O No if yes Regimen: __________ Start date : ____/___ /____ Months on ART Still on Treatment: O Yes O No
Client STATUS AT ENROLLMENT
VITAL SIGNS:- :- Temp ( C)________
o
PULSE/HR (/m)__________ BP (mmHg)_________RR (R/m)___________
ANRTOPOMETRY:- Height (cm) _____Weight (kg)_____ BMI (kg/m2)______ for child only; Head circumference (cm): _________
For child; anthropometry interpretation: O Normal weight for age O underweight
FUNCTIONAL Status:- O Working O Ambulatory O Bed ridden
Developmental status (for a child<5) O Appropriate for age O Delay O Regression
PRESENTING SYMPTOM
O Cough O weight Loss __% body wt O Dyspnea O Fever > 1 month O Nightsweat
O Diarrhea O Mental Confusion O STI Symptoms O Dysphagia/ Odynophagia
O Nausea and/or vomiting O Persistent Headaches O Others specify: ________________________________________
CLIENT’S PREGNANCY STATUS at Enrollment:
O Pregnant LMP / / EDD / / O Not Pregnant O Not Applicable
CLIENT GENERAL APPEARANCE OF AT Enrollment:______________________________________________________________________
Physical Examination by system
System Normal Abnormal Specify Abnormal Finding
HEENT
Lymph nodes
Chest
Heart
Abdomen
Genitourinary System
Musculo-skeletal
system
Skin
Nervous System
WHO HIV Clinical Stage at enrollment: ________ why: ________________________________
POSITIVE HEALTH DIGNITY AND PREVENTION (PHDP) ISSUE ADDRESSED
Dat Basic HIV Preventio Positi Progre Available Educatio Why Explain What side What to Conclusio
e & TB n: ve ssion treatment/ n on complete dose, effects & do if one n
transmissi abstinen living of prophylaxi essential adherence when to how to forgets
on ce, safer diseas s CPT, s of ART needed take manage dose
education, sex, e IPT,FPT
condoms
INSTRUCTIONS: Intake form- B Past and presenting illness & PHDP

Note: All fields must be completely filled in at enrollment then after should be update accordingly & all date fields must use Ethiopian calendar in DD/MM/YY format
Health Facility Name – Health Facility name as registered at the Ministry of Health
Medical Record Number (MRN): Unique individual identifier on medical information provided by facility on folder
Past Opportunistic Illness (OIs):– Mark all IOs that the patient has experienced before enrollment. Note: that this information can be obtained from the client, medical/lab records or
referral form
Past Prophylaxis / Treatment:-
Cotrimoxazole (CTX): If client is on CTX at enrollment enter the start date; using Ethiopian calendar in DD/MM/YYYY
Isoniazid (INH): If client on INH at enrollment enter the start date and if client has completed the INH enter stop date using Ethiopian calendar in DD/MM/YYYY format
ARV for PMTCT: Mark appropriate circle to indicate client exposure to ARV for PMTCTE, if yes enter facility name and the regimen given to the mother and the baby
Lifelong ART/TI: For all transfer in, mark ART status at enrolment, enter the regimen, how long the client was on ART, start date in DD/MM/YY format, & if the client is still on
ART
VITAL SIGNS:- Check and enter the measurement: temperature in OC, Pulse(PR) in rate per minute Blood pressure (BP) in mmHg Respiratory rate (RR) in rate per minute
Anthropometric Measurement:- measure and enter: Height in cm, Weight in kg, body mass index (BMI) in KG/ M2
Functional Status:- Assess & mark appropriate circle: Working if able to perform usual work in & out of house, Ambulatory if Able to perform activities of daily living but not able
to work Bedridden (B)=not able to perform activities of daily living
Developmental status for children <5 years:- A= Appropriate if a child has attained milestones for age: Delay: if the child failure to attain milestones for age Regression: loss of
what has been attained for age
Presenting Symptom: Ask and mark all the symptoms that the e client complain to have at enrolment
Client’s pregnancy status at enrolment: If pregnant enter Date of last Menstrual Period (LMP) & Expected Date of Delivery (EDD) otherwise mark appropriate circle
Client general appearance at enrollment: Assess and describe the general prance of the clients in the space provided
Physical Examination: Assess and mark appropriate physical finding category for each system; and describe all abnormal findings
WHO HIV Clinical Stage: Assess and stage the clients; enter the criteria (from past /presenting finding) used to put the client on a particular WHO clinical stage; listed below
WHO HIV Clinical Stage 1:
-Clinically Asymptomatic Client -Persistent Generalized Lymphadenopathy (PGL)
WHO HIV Clinical Stage 2:
-Minor Mucocutaneous Manifestations - Herpes Zoster - 5-10% body weight loss - Recurrent upper respiratory tract infection
WHO HIV Clinical Stage 3:
- Oral Candidiasis -Unexplained Chronic Diarrhea (>1 month) - >10% of Body Weight loss - Oral Hairy Leukoplakia
- Unexplained Prolonged Fever (>1 month) - Pulmonary Tuberculosis - Bacterial Pneumoni Unexplained anemia (<8g/dl),
neutropaenia (<0.5x109/l) and/or chronic thrombocytopaenia (<50 x 109/L) -Other Severe Bacterial Infections (eg. pyomyositis)
WHO HIV Clinical Stage4:
- Extrapulmonary Tuberculosis -HIV Wasting Syndrome - Atypical Mycobacteriosis -Candidiasis (Esophagus, Trachea, Bronchi or Lungs)
- Crytococcosis Extrapulmonary - Cryptosporidiosis with Diarrhea (>1 month duration) -Herpes Simplex (mucocutaneous >1 month, or visceral - CMV Disease (other than
liver, spleen, lymph nodes) -HIV Encephalopathy - Karposi’s Sarcoma
- Lymphoma - PML - Mycosis, Disseminated (i.e. Histoplasma, Coccidioides) - Pneumocystis Carinii Pneumonia (PCP) - Salmonella Septicemia, Non-typhoid -
Toxoplasmosis of the CNS - Symptomatic HIV-associated - Invasive cervical carcinoma
- nephropathy or cardiomyopathy - Atypical disseminated leishmaniasis
POSITIVE HEALTH DIGNITY AND PREVENTION PHDP) ISSUE ADDRESSED
Enter the date of adherence counseling in DD/MM/YY format and mark all issues raised and dressed during PHDP counseling