SayPro Pre-Exposure Prophylaxis (PrEP) Screening Log Form

WhatsApp/Call: + 27 84 313 7407 Email: info@saypro.online

SayPro is an award-winning company that provides solutions for government, corporate businesses, non-profit organisations and individuals globally and in Africa. Speak to us about this solution now. Chat to us on WhatsApp down on left.

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

SayPro Pre-Exposure Prophylaxis (PrEP) Screening Log

Pre-Exposure Prophylaxis (PrEP) Screening Log

 

 

 

 

DATE

 

 

 

 

CLIENT ID NUMBER

 

 

 

 

GIVEN NAME

 

 

 

 

SURNAME

 

 

GENDER

(M / F/TG / O /

No Response)

 

 

 

AGE

(years)

 

 

KEY POPULATION?

If yes, see codes*

HIV TEST COMPLETED THE PrEP SCREENING FOR SUBSTANTIAL RISK AND ELIGIBILITY FORM  

 

 

ELIGIBLE FOR PrEP?

 

 

 

SERVICES

(tick one)

PrEP ACCEPTED OR DECLINED?

(only if PrEP

was offered)

 

 

REASON FOR DECLINING PrEP

(see codes**)

 

 

 

PrEP CLIENT NUMBER

(if accepted)

 

 

DATE TESTED

 

 

RESULT

(Neg/Pos/Inc)

Yes/No (circle one) Yes Yes PrEP Offered

Referred for PEP

Referred for PCR/HIV Ag or HIV re-testing

 

PrEP Accepted

PrEP Declined

No No
Yes/No (circle one)  

Yes

 

Yes

 

PrEP Offered

Referred for PEP

Referred for PCR/HIV Ag or HIV re-testing

 

PrEP Accepted

PrEP Declined

No No
Yes/No (circle one) Yes Yes PrEP Offered

Referred for PEP

Referred for PCR/HIV Ag or HIV re-testing

 

PrEP Accepted

PrEP Declined

No No
Yes/No (circle one) Yes Yes PrEP Offered

Referred for PEP

Referred for PCR/HIV Ag or HIV re-testing

 

PrEP Accepted

PrEP Declined

No No
Yes/No (circle one) Yes Yes PrEP Offered

Referred for PEP

Referred for PCR/HIV Ag or HIV re-testing

 

PrEP Accepted

PrEP Declined

No No
Yes/No (circle one) Yes Yes PrEP Offered

Referred for PEP

Referred for PCR/HIV Ag or HIV re-testing

 

PrEP Accepted

PrEP Declined

No No
Yes/No (circle one) Yes Yes PrEP Offered

Referred for PEP

Referred for PCR/HIV Ag or HIV re-testing

 

PrEP Accepted

PrEP Declined

No No
Yes/No (circle one) Yes Yes PrEP Offered

Referred for PEP

Referred for PCR/HIV Ag or HIV re-testing

 

PrEP Accepted

PrEP Declined

No No
Yes/No (circle one) Yes Yes PrEP Offered

Referred for PEP

Referred for PCR/HIV Ag or HIV re-testing

 

PrEP Accepted

PrEP Declined

No No
Yes/No (circle one) Yes Yes PrEP Offered

Referred for PEP

Referred for PCR/HIV Ag or HIV re-testing

 

PrEP Accepted

PrEP Declined

No No
Yes/No (circle one) Yes Yes PrEP Offered

Referred for PEP

Referred for PCR/HIV Ag or HIV re-testing

 

PrEP Accepted

PrEP Declined

No No
Yes/No (circle one)  

Yes

 

Yes

 

PrEP Offered

Referred for PEP

Referred for PCR/HIV Ag or HIV re-testing

 

PrEP Accepted

PrEP Declined

No No

*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).

 

**REASONS FOR DECLINING PrEP: 1—No need for PrEP. 2—Does not wish to take a daily medication. 3—Concerns about side effects. 4—Concerns about what others might think.

5—Concerns about time required for clinic follow-up. 6—Concerns about safety of medication. 7—Concerns about effectiveness of medication. 8—Other (specify).

Share on facebook
Share on twitter
Share on linkedin
Share on pinterest

Leave a Comment

error: Please note copying is not allowed and not healthy for you. SayPro
Subscribe to our newsletter

Sign up to receive updates, promotions, and sneak peaks of upcoming products. Plus 20% off your next order.

Promotion nulla vitae elit libero a pharetra augue