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 |
|
|
|
|
|
|