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Demographic information section
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HIV care & family status section
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Antiretroviral therapy status section
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OP encounter-level info section
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Patient Last name
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HIV confirmation facility Add
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Date next screen visit:Date:Pt:^Patient:Qn:CPHS
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HIV Rx prior to enrollment
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Patient First name
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HIV confirmation facility
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Current HIV Rx duration
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Date eligible to start HIV Rx
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Inst entry point HIV Rx
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Sex
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Hx of Functional status
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Reason medically eligible for HIV Rx
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District where patient entered HIV Rx
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WHO HIV stage
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E
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Birth date
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{mm/dd/yyyy}
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WHO HIV stage
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E
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Phone #
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CD3+CD4+ Cells NFr Spec
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%
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Body weight:Mass:Enctr^frst:^Patient:Qn:Measured
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HIV1 Ab Patrn Ser IB-Imp
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CD3+CD4+ Cells # Spec
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/uL
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Body height Measured
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Date eligible & ready to start HIV Rx
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HIV 2 Ab Patrn Ser IB-Imp
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TB status
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TB Tx start date
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Date eligible & selected to start HIV Rx
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Pregnancy status Reported
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E
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HIV Rx prior clinic transferred from Add
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Family planning.status:Find:Pt:^Family:Ord:Observed.OMAHA
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HIV Rx prior clinic
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Birth control method Reported
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Date original clinic HIV Rx start
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Reason for follow-up (referred to) provider &or specialist:Find:Pt:Clinical referral:Nom:CPHS
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HIV Rx cohort
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Hx of Functional status
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Follow-up (referred to) provider &or specialist, provider type:Type:Pt:Clinical referral:Nom:CPHS
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Body weight:Mass:Enctr^frst:^Patient:Qn:Measured
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Follow-up (referred to) provider &or specialist, address:Addr:Pt:Clinical referral:Nom:CPHS
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Body height Measured
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Med/other side effects assoc with HIV Rx
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Date dropped from HIV Rx
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Severity of side effect to HIV Rx
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Date of death
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Reason for d/c of anti-infect proph Rx
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Reason for missing HIV Rx schedule
E
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# hosp days since last OP visit Reported
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{#}
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