Enrollment date: Enrolled at:
Mch Child Services Follow-up Card(Enrollment)
Cohort by month and year of Birth: MM-YYYY
INFANT PROFILE
Child Exposed?
HEI ID Number SPD No Birth Weight: (kg)
Gestation at birth(weeks) Date first seen
Birth Notification Number
Certificate of Birth Registration Number:(after acquiring a certificate)
Child need special care?
Reasons For Special Care(Tick as appropriate)









Source of Referral
Transfer in?
Transfer in date: Transferred from facility:
in district: Date first enrolled in HEI care:
ARV Prophylaxis
Is the mother Breastfeeding?
NVP during BF?
History of TB Contact in Household? Screen for TB; and appropriately refer for INH Prophylaxis
PARENT'S PROFILE(Edit using Relationship Section)
Name of Mother
Mother Alive? Name of Father
Mother received Drugs for PMTCT?
Select the combination
On ART at Enrollment of Infant Enter regimen Parent's CCC No.
Mode of Delivery Place of Delivery