HIV/AIDS Outpatient Monitoring Template
Patient Information
Name
Date of Birth
Medical Record Number
Visit Information
Date of Visit
Provider
Clinical Assessment
Symptoms/Complaints
Physical Examination
Vital Signs
Weight (kg)
Blood Pressure (mmHg)
Temperature (°C)
Heart Rate (bpm)
Laboratory Results
CD4 Count
Viral Load
Other Lab Results
Antiretroviral Therapy (ART)
Current ART Medication
ART Adherence
Good
Fair
Poor
Other Medications
Other Medications
Additional Notes / Next Appointment
Notes
Next Appointment