Microsoft word - nhp application - afa.doc

APPLICATION FORM – CONFIDENTIAL
FIRST PAGE – TO BE COMPLETED BY APPLICANT
EMPLOYEE DETAILS
Employer:
confidential mail:
Treatment Support is a vital part of the AfA programme. Contact details must be supplied in order that we can provide you with this support.
Would you like to receive SMS notification Would you like to receive information via
OTHER DOCTORS OR SPECIALISTS (that you are seeing in addition to the doctor filling in this form):
I consent to being registered on the HIV/AIDS programme and take note that I will also be required to sign a separate consent form. I furthermore warrant that the information supplied above is correct and that I have read and understood the contents of this form. I understand that acceptance onto Aid for AIDS means that an AfA treatment support counsellor will contact me. PATIENT’S SIGNATURE:
____________________________________________________________ PLEASE FAX COMPLETED FORM WHERE POSSIBLE PAGES 2 – 4 : TO BE COMPLETED BY THE ATTENDING MEDICAL PRACTITIONER
DETAILS OF THE DOCTOR WHO WILL BE PROVIDING ONGOING CARE:
Doctor’s Surname:

1. CLINICAL HISTORY (Current diagnosis and medication recorded under Point 4.)
1.1
When was HIV infection first diagnosed? (Please attach reports.) Is the patient currently being treated for tuberculosis? Has the patient previously been exposed to antiretrovirals? Previous antiretroviral Exposure Note: If the application is for a baby please list mom's previous ART history. Please list all other medication the patient is taking, including prophylaxis: Is the patient allergic to any medication? INFORMATION REQUIRED TO PREVENT ADVERSE SIDE-EFFECTS OF CERTAIN DRUGS:
1.8
Is there a history of heavy alcohol intake? (i.e. more than 4 drinks per day for a long period of time) Is there a history of recreational drug use? (Cannabis, Cocaine, Ecstasy, LSD etc.) 1.10 Is there a history of depression or psychiatric illness? If yes, specify treatment:
PLEASE FAX COMPLETED FORM WHERE POSSIBLE
2. CLINICAL EXAMINATION
2.1
(Please specify in Section 4 whether i/v or oral medicines are preferred during labour.) Clinical Stage I
Please tick Details
Clinical Stage II
Recurrent upper respiratory tract infections Clinical Stage III
Weight loss (= ___________kg), >10% of body weight Unexplained chronic diarrhoea > 1 month Severe bacterial infections (i.e. pneumonia) Clinical Stage IV
AIDS defining opportunistic infection*. Please specify: _______________________________________________ * For list of AIDS defining opportunistic infections, please see AfA Clinical Guidelines booklet or www.aidforaids.co.za
2.6
Is there any degree of peripheral neuropathy? Is there any other significant clinical finding? PLEASE FAX COMPLETED FORM WHERE POSSIBLE 3. SPECIAL INVESTIGATION RESULTS (Please provide copies of reports. Please supply as many results as possible.)
Date Test Performed (DD/MM/YYYY)
CD4 count (cells / mm)
Viral Load (copies / ml)
Additional Investigations
Test Done?
If yes, results
Date Test Performed
Blood count(s) (Essential prior to approval of Zidovudine) Baseline ALT (Essential prior to approval of Nevirapine Creatinine clearance or serum creatinine (Essential for patients with renal failure)
4. MEDICATION (NB: Generic equivalents will be authorised unless otherwise stated)
4.1 ANTIRETROVIRAL THERAPY
4.2 Other Medication Required (associated with the management of HIV)
ACKNOWLEDGEMENT BY EXAMINING DOCTOR:
I certify that the above particulars are – to the best of my knowledge and belief – true and accurate, having conducted a personal examination and procured
the tests and/or other diagnostic investigations referred to. I acknowledge that Aid for AIDS will rely on such particulars when making any treatment
recommendations/authorisations for patients registered on the HIV/AIDS Programme.
I acknowledge that telephonic discussions with Aid for AIDS will be taped for medico-legal purposes.
Surname Name
Doctor’s
Signature
PLEASE FAX COMPLETED FORM WHERE POSSIBLE

Source: http://www.nhp.com.na/cms_documents/c77-aid4aids.pdf