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Form for Elderly HIV

Personal details:

1. Name
2. Age
3. Sex
4. Marital status.
5. Residence
6. Telephone no: Mobile no:
7. Occupation
8. Education.
9. Socio-economic status.
10. Addiction.
11. Care giver’s name, address & telephone number
12. Date of diagnosis:
13. Place of diagnosis:
14. Sexual practice
15. Spouse status
16. Possible route of transmission
14. Place where receiving treatment.
Co-morbidities:
1. Hypertension:

When diagnosed Medicines Adherence to Control


prescribed medicines

2. Diabetes mellitus

When diagnosed Medicines Adherence to Control


prescribed medicines

3. Heart disease

Type of disease When Medicines Adherence to Control


diagnosed prescribed medicines
IHD

Cardiomyopathy

Any other
4. Kidney disease

Type of disease When Medicines Adherence to Control


diagnosed prescribed medicines
CKD

BPH

others

5. Lung disease

Type of disease When Medicines Adherence to Control


diagnosed prescribed medicines
COPD

Bronchial
asthma

others

Chief complains:

General survey (including genitalia):

Systemic examination:
GI:
RESP:

CVS:

CNS:

MMSE score

INVESTIGATION:
Routine: Hb%. TC: DC: Platelet count ESR
FBS:
Urea: Creatinine:
LFT :
Lipid Profile:
VDRL
HBsAg Anti HCV :
Blood culture
Urine R/E
Urine culture
Stool: Routine: Special pathogens:
CXR:

USG:
CT brain/MRI

CSF

CD4 count:

Any other special investigation :

Opportunistic infections/malignancies:

Name of When Mode of Treatment Place Completed Outcome of


disease diagnosed diagnosis given being on/continu treatment
treated ing (if completed)
Oral candidiasis

Pulmonary
Koch’s

Extra-
pulmonary
Koch’s

Pneumonia

Cryptococcal
infection

Toxoplasmosis

Diarrhoea

HAND

PMLE

Syphilis

Other STI

UTI

Bacteremia

Malignancies

Any other

Details of antiretroviral therapy

When Where With Base Any Progress of CD4 count Any Any Outcome
started started which line drug virologic change
regimen CD4 toxicit al of regime
coun y testing (Substitu
t done tion/Swit
ch)
Any other comment:

Form filled up by:


Dr.
Mobile no.