ANM/Counselor
training
July 2003, 2012
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
FORM A
FORM B
FORM C
FORM C 1
FORM D
FORM E
FORM F
FORM FF
FORM G
FORM H
FORM I
FORM J
FORM K
FORM L
FORM M
FORM N
FORM O
FROM P
HRG registration form
Peer Educator Weekly Planning & Activity Sheet)
PE wise individual HRG compiled monthly sheet
Monthly summary sheet
Outreach weekly report
HRG master register
Patient register format
Clinic daily summary sheet
Medicine stock register
Referral slip and Register
Counseling register
Advocacy activity report
Crisis Management Register
Training register
Drop in center register
Commodity stock register
Movement register
Community mobilization activity register
1.
FORM A
HRG registration form
ORW
2.
FORM B
Peer Educator Weekly Planning & Activity Sheet)
PE
3.
FORM C
PE wise individual HRG compiled monthly sheet
ORW
4.
FORM C 1
Monthly summary sheet
ORW
5.
FORM D
Outreach weekly report
ORW
6.
FORM E
HRG master register
M&E
12.
FORM J
Advocacy activity report
PM
13.
FORM K
Crisis Management Register
PM
14.
FORM L
Training register
PM
15.
FORM M
Drop in center register
PM
16.
FORM N
Commodity stock register
PM
17.
FORM O
Movement register
PM
18.
FROM P
Community mobilization activity register
PM
Management of
STIs
Condom
Promotion
Behaviour Change
Communication
HRGs
Referrals &
Linkages
Enabling
Environment
Community
Mobilization
National AIDS Control Organisation, Ministry of Health & Family Welfare, Govt. of India
STI / RTI Patient wise Record
Date
Provider Name
Marrital Status: UM / M / Single / Divorced / Widow(er)
Patient ID Number
Clinic Name
Clinic Unique ID No.
Patient Name
Education: UE / <5th / <10th / 12th / > inter
Occupation
Income:
Patient OP Number
HRG ID Number
Patient Details:
1.Age
2.Sex
Male
Female
Transgender
3.Type of Client/Pt.
New
Old
4.Category of the Pt.
Gen. Population
Bridge Population
Mention:
HRG
FSW
MSM
IDU
5. Patient Flow
Direct Walkin
Referred
From:
6.STI / RTI Risk Assessment:
Medical History Taken
Sexual History Taken
Physical Exam. Conducted
Speculum and/or Proctoscopic exam conducted
Known HIV Positive
Significant points in bullets from Medical & Sexual
History:
7.STI / RTI Syndromic diagnosis :
Urethral Discharge (UD)
GUD - Herpis(GUD-H)
GUD - Non Herpis(GUD-NH)
Scrotal Swellings(SS)
Inguinal Bubo(IB)
Genital scabies
Anorectal Discharges(ARD)
Gen. Molluscum
Examination findings :
Vagino-Cervical Discharge(VCD)
Genital Pediculosis
Genital Warts
Lower Abdominal Pain(LAP)
Asymptomatic
Syphilis Screening
Presumptive Theraphy (PT)
Others (specify) -
12.Type of visit
New STI/RTI
Follow up visit
Asymptomatic
General
Regular Medical Checkup (RMC)
Syphilis screening
9.Details of STI/ RTI Treatment given
Kit (If available)
Kit 1 (Grey for UD/ARD/CD/PT)
(1Tab.Azithromycin.1gr+1Tab.Cefixime.400mg)
Kit 2 (Green for Vag.Discharge)
(1tab.Flconazole.150mg+2tab.Secnidazole.1gr)
Kit 3 - White for GUD(NH)
(1vial of Inj.Benzathiene Pencillin 2.4MU+1tab.Azithromycin 1gr)
Kit 4 (Blue for GUD(NH)
(30 tab.Doxycycline.100mg+1 tab.Azithromycin 1gr)
Kit 5 (Red for GUD(H) - (21 tab.Acyclovir 400mg)
Kit 6 (Yellow for LAP)
(1tab.Cefixime 400mg+28 tab.Metronidazole 400mg+28 cap.Doxycycline
100mg)
10.If kits are not available Drugs Prescribed/ Issued
P
I
P
I
Acyclovir 400 mg
Permethrin 5% & 1%
Amoxicillin 500 mg
Podophyllin 20%
Azithromycin 1gm
Tricloroacetic acid 30%
Benz. Penicillin 2.4 MU
General Medicines
Benzyl Benzoate 25%
Adrenaline
Cefixime 400 mg
Antihistaminics
Ceftriaxone 250 mg & 1 gm
Hydrocortisone
Ciprofloxacin 500 mg
Ibuprofen
Clotrimazole 500 mg
Doxycycline 100 mg
Metoclopramide
Ranitidine
Erythromycin 500 mg
Fluconazole 150 mg
Kit 7 (Black for IB)
Metronidazole 400 mg
(42 tab.Doxycycline+1 tab.Azithromycin 1gr)
Secnidazole 2gr
Other treatment given
__ __ __ __ / __ __ --- __ __
8.Lab Test performed:
RPR
Reactive
Titre
Confirmed with TPHA
Gram Stain
ICDC
WBC
Nugent's Score
H.ducreyi
None
KOH
Whiff test +ve
Psedohypha/Spores
None
Wet Mount
Motile Trichomoniasis
Clue cells
None
HIV
Non Reactive
Reactive
if reactive,
Stage of PLHA from ART Centre
11.Others services provided
11.1.Patient Education
11.4.Referrals
Partner Treatment
From
To
Condom Usage
ICTC
Other risk reduction
ICTC (PPTCT)
DMC
11.2.Partner Treatment
Care & Support Centre
Prescription written
ART Centre
Medication given
PLHA network
Refferalslip provided
NGO
Others
Specify:
11.3.Condom
Given free
IEC material given
Sold / Social Marketed
Append result if any
Prescribed
other tests performed
Demonstrated
Next Follow Up day: 3 / 7 / 14 / 21 days