Pediatric Mastercard for Children Not Yet on Arvs

Pediatric Mastercard for Children not yet on ARVs Registration Date ______d d / m m / y y y y First Name: ______HIV Diagnosis: Age at Diagnosis:______Last Name: ______Type of Test: RT PCR Sex:  Male  Female d d m m y y y y d d m m y y y y Date of test ______/ ______/ ______D.O.B.*: ______/ ______/ ______Initial WHO Stage (circle here and on back): I II III IV Clinic Site______

New WHO Referrals Staging (NRU, TB, ward, etc.) To Date Age Weigh Length MUAC Wt/Ht Nutritional Warniing Condition?3 CD4 CPT Other Next Start t (kg) (cm) (cm) % Status1 signs?2 (circle & date on Diagnoses or Comments Appointment ART? back) (dd/mm/yy) dd mm yy N M S Y N Stage CD4 Date Y N Y N

1 NUTRITIONAL STATUS CODES: N=normal; M=moderate malnutrition; S=severe malnutrition 2 WARNING SIGNS: H= Hospitalization since last visit, D= Diarrhea; F= Fever; C= Cough; R= Rash; T= Thrush; O=other

3 Staging criteria: diarrhea > 2 weeks?, fever > 1 month?, oral thrush?, TB?, other staging condition?