CONSULTATION CENTER

NAME OF

CONSULTING SERVICE

SERVICE ID

PATIENT IDENTIFIER IN THE

DEPARTEMENT

PATIENT ID IN WORK

_ _ _ / RA / ARV 12 / 2021 / _ _ _ / _ _ _ _

PATIENT

INITIAL OF NAME

FIRST NAME INITIAL

INITIAL OF POST-NAME

TELEPHONE NUMBER

FULL ADRESS

PLACE AND DATE OF BIRTH

AGE

SEX

SIZE

WEIGTH

BODY MASS INDEX (BMI)

TEMPERATURE OF PATIENT

MARITAL STATUS

OCCUPATION

LEVEL OF STUDY

RELIGION

PROVINCE OF ORIGIN

TRIBE

HIV TESTING

DATE

PLACE

METHOD

EXPOSITION ANTERIEUR AUX ARV

YES □

NO □