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 |
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TELEPHONE NUMBER |
| |||
FULL ADRESS |
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PLACE AND DATE OF BIRTH |
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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 □ |