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rhcd.txt
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rhcd.txt
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Enrolment/Patient start at the clinic
Patient details
1 Date of form completion 00 / 00 / 0000
2 Patient Hospital ID
Patients initials 000
Last First Middle
3 Date of birth 00 / 00 / 0000
4 Age 00 Years
5 Sex 0
6 Date patient enrolled at the clinic 00 / 00 / 0000
HIV History
7 When was the diagnosis made? 00 / 00 / 0000
8 Date antiretroviral therapy commenced 00 / 00 / 0000
9 Current ARV regimen
Previous ARV regimens
10 Previous regimen 1
Date commenced
Date ended
Reason for switching
11 Previous regimen 2
00
Date commenced
00 / 00 / 0000
Date ended
00 / 00 / 0000
Reason for switching
Non-communicable disease history
12 Did the patient have Diabetes when they started attending the clinic?
0
13 If YES, when was the diagnosis of diabetes made? 00 / 00 / 0000
14 List of diabetes treatment when patient started attending the clinic
15 Did the patient have Hypertension when they started attending the clinic?
0
16 If YES, when was the diagnosis of hypertension made? 00 / 00 / 0000
17 List of hypertension treatment when patient started attending the clinic
Baseline data (Recorded when patient first started attending the clinic)
18 Height 000 centimeters
19 Weight 000 Kgs
20 Waist 000 centimeters
21 Blood pressure 000 Systolic (mmHg)
000 Diastolic (mmHg)
22 Blood glucose
00.0mmol/L OR 000 mg/dL
23 Was this a fasting or random blood glucose? 0
Blood results
24 Total cholesterol 00.0 mmol/L
25 LDL 00.0 mmol/L
26 HDL 00.0 mmol/L
27 Triglycerides 00.0 mmol/L
28 Serum urea levels (mg/dl) 00.0mg/dl or 00.0mmol/L
29 Serum creatinine levels (mg/dl) 0.0mg/dl or 000.0 µmol/L
30 CD4 count 0000cells/mm3
31 Date of CD4 count 00 / 00 / 0000
32 Viral load 000000copies/ml
33 Date of Viral load 00 / 00 / 0000
Investigations
34 Chest X-ray
Choose from findings listed (you can enter up to 2 findings)
0
0
35 ECG findings
0
36 ECHO findings
0
HIV retrospective cohort. Follow up CRF
Patient details
1 Date of form completion 00 / 00 / 0000
2 Patient Hospital ID
Patients initials 000
Last First Middle
3 Date patient last seen at the clinic 00 / 00 / 0000
4 Is the patient alive and in care? 0
5 Since the patient started at this clinic, have they developed diabetes?
0
6 If YES, when was the diagnosis of diabetes made? 00 / 00 / 0000
7 List of diabetes treatment.
8 Since the patient started at this clinic, have they developed hypertension? 0
9 If YES, when was the diagnosis of hypertension made? 00 / 00 / 0000
10 List of hypertension treatment.
If the patient has developed either hypertension or diabetes, have any of the following complications occurred?
11 Stroke 0
If yes, date of diagnosis
00 / 00 / 0000
12 Diabetic foot 0
If yes, date of diagnosis
00 / 00 / 0000
13 Chronic heart failure 0
If yes, date of diagnosis
00 / 00 / 0000
14 Chronic renal failure 0
If yes, date of diagnosis
00 / 00 / 0000