SayPro Pre-Exposure Prophylaxis (PrEP) Client Register

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Email: info@saypro.online
Call: + 27 11 071 1903
WhatsApp: + 27 84 313 7407

SayPro Pre-Exposure Prophylaxis (PrEP) Client Register

Pre-Exposure Prophylaxis (PrEP) Client Register
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA AB AC AD AE AF AG AH AI AJ AK AL AM AN AO AP AQ AR AS AT AU AV
Date of PrEP Initiation Client ID Number PrEP Client Number                 (if applicable)  Surname Given Name Address Telephone Alternative Telephone Date of Birth Age (years) Sex at Birth (M/F/O /No R) Gender
(M/F/TG/O
/No Response)
Key populations client?
(Y/N)
PrEP (ARVs)
Prescribed
Follow-Up Visit 1  Follow-Up Visit 2 Follow-Up Visit 3 Follow-Up Visit 4 Follow-Up Visit 5 Stopped PrEP Re-Initiation of PrEP Outcome
Visit Date HIV
Testing
PrEP Side Effects
(see codes)
PrEP (ARVs)
Prescribed
Visit Date HIV
Testing
PrEP Side Effects
(see codes)
PrEP (ARVs)
Prescribed
Visit Date HIV
Testing
PrEP Side Effects
(see codes)
PrEP (ARVs)
Prescribed
Visit Date HIV
Testing
PrEP Side Effects
(see codes)
PrEP (ARVs)
Prescribed
Visit Date HIV
Testing
PrEP Side Effects
(see codes)
PrEP (ARVs)
Prescribed
Date Reasons
(see codes)
Date                    (Enter visit information in first available follow-up column) Stopped Date Reasons
(see codes)
PrEP Follow-Up Outcome
(tick outcome that applies)
Code
(see below)
Date
Tested
Result (Neg/Pos/Inc) Date
Tested
Result (Neg/Pos/Inc) Date
Tested
Result (Neg/Pos/Inc) Date
Tested
Result (Neg/Pos/Inc) Date
Tested
Result (Neg/Pos/Inc) Died Lost to Follow- Up Transfer Out
1 Y/N [ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
2 Y/N [ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
3 Y/N [ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
4 Y/N [ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
5 Y/N [ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
6 Y/N [ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
7 Y/N [ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
8 Y/N [ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
9 Y/N [ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
10 Y/N [ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
11 Y/N [ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
12 Y/N [ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
[ ] TDF/FTC
[ ] TDF/3TC
[ ] TDF
[ ] Other________
CODES
PrEP SIDE EFFECTS CODES:     A=Abdominal pain.   S=Skin rash.   Nau=Nausea.  V=Vomiting.   D=Diarrhea.   F=Fatigue.  H=Headache.   L=Enlarged lymph nodes.  R= Fever.  O=Other (specify).
REASONS FOR STOPPING PrEP CODES:    H=Tested HIV+.   R=No longer at substantial risk.   S=Side effects.   C=Client preference.   AB=Abnormal creatinine result.   O=Other (specify).
KEY POPULATION CODES:    MSM=Man who has sex with men.    TG=Transgender.   SW=Sex worker.   PWID=Person who injects drugs.   PP=Person in prison.   O=Other (specify).
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