Date: Facility:
Patient's Names:
Patient Clinic Number: Date of Birth: Age:
ARV THERAPY
Date Medically Eligible
Eligible Thru.?
WHO Stage CD4 Count CD4 %
Date Started on 1st Line:
COHORT: Regimen:

At Start of ART:
Weight(kgs): Height(cms): WHO Stage
Transfer Out and Death
Dates Event Where?
Patient Transferred Out
Patient Died
ART Treatment Interruptions
Dates Reason for Interruption Reason for Stop Date Restarted