UGANDA SITES PEADIATRIC FOLLOW UP VISIT FORM

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					                         UGANDA SITES: PEADIATRIC FOLLOW UP VISIT FORM


Patient Name: (surname/middle/given name)                Unique I. D:……………………………………..
                                                         Clinic I.D:……………………………………….
                                                         Cohort:……………/……………………..( mm/yy)
Date:……..../………..…/……..…(d/m/y)  Scheduled visit         Unscheduled visit
Site:  Masaka RRH                     Mbale RRH         Mbarara University Teaching Hospital
Change of care taker:  Yes       No
If yes; specify:……………………………………………………………………………………………………………………..
Change of address/ phone contact:  Yes                 No
New address: District:……………………………………..Sub county:………………………………………………………..
Parish:……………………………………………………….LC1………………………………………………………………..
Phone contact :…………………………………………….( whose)…………………………………………………………
Medicines picked by :……………………………………...( relation to client)…………………………………………………..
CLINICAL ASSESSMENT
Vital signs: Weight:…………(kgs) Temperature………….(ºC) Height:…………….(cm)
Head circumference………….(cm) Mid upper arm circumference…………………..(cm)
HISTORY:
Tuberculosis:
 No signs  Suspect  Completed treatment  On treatment
If on treatment:  Initial phase  Continuation phase  Re- treatment  Defaulted
Current Medication:
ARVs:  Yes           No
Prophylaxis:  Cotrimoxazole  Diflucan  INH  Dapsone
ADHERENCE:
ARVs:
Number of doses missed in last month:………………………………………………
 Good (≥ 95%)  Fair (85 – 94%)           Poor (< 85%)
Reason for poor adherence:
 Toxicity  Felt better  Too ill  Stigma/ disclosure issues  Travel problems  Depression        
Drug out of stock  Forgot  Patient run out of pills  Alcohol consumption  change of care taker 
Other
New symptoms and signs:
None Oral thrash Oral ulcers Vomiting Diarrhoea Rash Headache Molluscum contagiosum
Cough Haemoptysis Fever Weight loss  Paralysis Dysuria Genital sores Visual impairment
Regression of milestones Other

Comment:……………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………
SIDE EFFECTS OF ARVs:
 None  Fatigue  Nausea  Vomiting  Diarrhoea  Jaundice  Rash  peripheral neuropathy
 Lipoatrophy  Anaemia  Abdominal pain  Nightmares  Dizziness  Depression
Comment:…………………………………………………………………………………………………………………………..



                                                     1
…………………………………………………………………………………………………………………………………………
…….
PHYSICAL EXAM FINDINGS:
General:  Jaundice  Anaemia  Oedema  Lymphadenopathies  Other
System specific;
(comments)…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………
……..
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
LABORATORY:
Test    CD4      CD4   WBC     Neutrophils   Lymphocytes   Platelets   HB   LFTs   Creatinin   sputum   CXR   RPR   Other
        count    %     Total
Tick
WHO STAGE:  1       2                        3                4
Diagnosis:
FUNCTIONAL STATUS:  Working                      Ambulatory  Bedridden
KPS ( coded)
New Problem:

TREATMENT:
ARVs:
 Not eligible  Eligible, not ready to start  Eligible ready to start  Start  Switch to 2nd line  Stop
 Substitute  Continue. If continuing, duration on ART……………………………………………………………

Reason for starting/eligibility criteria:  Clinical  CD4  Total lymphocyte count  Transfer in on ART

Reason for not starting when eligible:
 Drug out of stock  Patient not ready  No treatment supporter  Too ill  Other

Reason for switch / stop/ substitute:
 Toxicity/side effects  Pregnancy  Treatment failure  Poor adherence  Illness/hospitalisation  drugs
out of stock  planned treatment interruption  New TB treatment  New drug available  Other patient
decision  Lack of patient finances
 Other (specify)………………………………………………………………………………………..

Regimen:
 Triomune 30  Triomune 40  Combivir( AZT+3TC)  D4T20  Kaletra  D4T30  D4Tsyrup  3TC 
AZT  NVP  EFV syrup  EFV 200  DDI 50 DDI 200  DDI 400  ABC  NLF  SQV  T
 AZT Syrup

ARV Drug                       Dose                           Duration                         Amount supplied




Prophylaxis Drugs:
 Cotrimoxazole  Diflucan ( Fluconazole)  INH


                                                                2
Prophylaxis drug           Dose                     Duration                  Amount supplied



Additional Drugs Ordered
Drug                       Dose                     Duration                  Amount supplied




REFERRAL/ LINKAGE:           None
Internal:  Wards Maternal and Child Health (MCH)  Nutrition unit  TB clinic Other (specify)………….
Reason for referral:…………………………………………………………………………………………………………………..
 External:  Adherence/ support groups  CBO (Name)…………………………………. Other
site(where)………………………………………..
RETURN DATE:……………………………….(d/m/y)
Patient seen by:(Name and signature)

Medical Officer…………………………………………………………………Sign……………………………………………….

Clinical Officer:…………………………………………………………………Sign……………………………………………….

Nurse……………………………………………………………………………Sign…………………………………………………

Other:……………………………………………………………………………Sign……………………………………………….




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posted:12/29/2011
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