Mch Child Services Follow-up Card(Enrollment)
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Cohort by month and year of Birth: MM-YYYY
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INFANT PROFILE
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Child Exposed?
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HEI ID Number |
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SPD No |
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Birth Weight: (kg) |
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Gestation at birth(weeks) |
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Date first seen |
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Birth Notification Number
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Certificate of Birth Registration Number:(after acquiring a certificate)
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Child need special care? |
Reasons For Special Care(Tick as appropriate) |
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Source of Referral |
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Transfer in?
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Transfer in date: |
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Transferred from facility: |
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in district: |
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Date first enrolled in HEI care: |
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ARV Prophylaxis |
Is the mother Breastfeeding?
NVP during BF?
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History of TB Contact in Household?
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Screen for TB; and appropriately refer for INH Prophylaxis |
PARENT'S PROFILE(Edit using Relationship Section)
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Name of Mother
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Mother Alive? |
Name of Father
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Mother received Drugs for PMTCT?
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Select the combination
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On ART at Enrollment of Infant
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Enter regimen
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Parent's CCC No. |
Mode of Delivery |
Place of Delivery |