Scribd
Upload
22 views

Third Line ART Request Form - Revised

Gart

Uploaded by

Emmanuel selungwi
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
22 views

Third Line ART Request Form - Revised

Gart

Uploaded by

Emmanuel selungwi
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH

Third Line ART Request Form

(Filled at Referring Facility)


(Section A to C print from the CTC2 Database)

Section A (a): Facility information

Facility Referred from (Registration Name): ________________


Type of Facility:
Council: _______________ Region: ________________

(b): Patient information

Unique CTC ID (14 digits): ______________________________________


Date of birth: _____/_____/________ Age: ______ Sex: M / F
If Pregnant: EDD_____________
Marital status __________________ (as in CTC2 card)
Weight(kg) ___________ Height (m)___________

Referring 3rd line coordinator


Name of coordinator ______________
Cadre _____________ Signature: _________________
Phone number__________________ email: __________________

Section B: ART exposure and HVL testing


Date verified/confirmed HIV+ _____/_____/____ Date start ART ___/_____/_____
Date started Second line ART ___/___/____ Current second line ART regimen __/___/____

Page 1 of 4 Version 03: July2022


UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH

Previous ART regimen history (from first to current ART regimen)


Regimen Duration Reason to stop/change
Sn Interval
e.g, TDF/3TC/DTG (Months)
1. Start _____/_____/________
Stop/change _____/_____/________
2. Start _____/_____/________
Stop/change _____/_____/________
3. Start _____/_____/________
Stop/change _____/_____/________
4. Start _____/_____/________
Stop/change _____/_____/________
5. Start _____/_____/________
Stop/change _____/_____/________
6. Start _____/_____/________
Stop/change _____/_____/________
7. Start _____/_____/________
Stop/change _____/_____/________
8. Start _____/_____/________
Stop/change _____/_____/________
9. Start _____/_____/________
Stop/change _____/_____/________
10. Start _____/_____/________
Stop/change _____/_____/________

Section C: Current medical conditions and concurrent medications in the past 6 months
(e.g Co-morbidities, opportunistic infections)

ARV Regimen during


Diagnosis Treatment
Sn Treatment of the specific
(Refer Code 3 CTC2 card)
condition

1.
2.
3
4.
5.

Page 2 of 4 Version 03: July2022


UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH

CURRENT HVL RESULTS


1st HVL results (pre-EAC, within 6 months) ________________

Date sample taken: ___________ Date results received: ____________

2nd HVL results (post-EAC, within 3 months) _______________


Date sample taken: ___________ Date results received: ____________

Section D: Summary of Adherence Barrier identified during EAC sessions (refer to and
attach EAC form)
Behavioral: _________________________________________________________________
___________________________________________________________________________
Cognitive: __________________________________________________________________
___________________________________________________________________________
Emotional: _________________________________________________________________
___________________________________________________________________________
Social-economic:_____________________________________________________________
___________________________________________________________________________
Others (Specify):_____________________________________________________________
___________________________________________________________________________

Current Average adherence to ART (circle correct choice)


Good ≥ 95%
Poor < 95%

Page 3 of 4 Version 03: July2022


UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH

Section E: Laboratory and Radiological results


(filled at referring facility and referral/selected facility)
Baseline Most recent (1 Month)
Results (if no results,
Test Date Date Results (if no results, comment
comment on why not
Obtained obtained on why not available)
available)
CD4
Full Blood
Picture (results
interpretation)
Creatinine
Creatinine
clearance (CKD
Epi)
ALAT
ASAT
CrAg
Hep B Surface Ag
Total Cholesterol
HDL
LDL
Triglycerides
Fasting /Random FBG:
Blood Glucose RBG:
CXR

Section F: Recommendations from Referral and Facility MDT


Facility MDT: _______________________________________________________________
___________________________________________________________________________
Regional MDT: ______________________________________________________________
___________________________________________________________________________
Name: _____________________________ Signature: ________________ Date: _________

PLEASE ATTACH THE HIVDR SEQUENCING RESULTS IF ANY (for HIV infected
Infants attach Mother’s HIV DR results)

Page 4 of 4 Version 03: July2022

You might also like