RD4A - MENSANA SIOC - Primary Healthcare Assessment

SIOC - Primary Healthcare Assessment

Location

Location(*)

Please select a location!

Patient Number(*)

Please enter patient number!

Gender(*)

Male

Female

Please make a selection!

Age(*)

Please enter patient's age!

Nutritional assessment

Child growth standard

Sex

Invalid Input

Hight (in cm)(*)

Please enter height!

Weight(*)

Please enter weight!

BMI(*)

Please enter BMI!

Date of birth

Invalid Input

Classification

Invalid Input

Capture notes for nutritional assessments?(*)

Yes

Invalid Input

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Gross motor

Left leg - hop count

Right leg - hop count

Number

Invalid Input

Number

Invalid Input

Capture notes for gross motor

NoYes Invalid Input

Fine motor

Left hand(*)

Normal

Abnormal

Invalid Input

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Right hand(*)

Normal

Abnormal

Invalid Input

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Capture notes for fine motor?

No Yes Invalid Input

Maternal Health

Antenatal 1st visit(Before 20wks)*(*)

Yes

Invalid Input

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Antenatal - HIV Test*(*)

Yes

Invalid Input

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Postnatal within 6 days*(*)

Yes

Invalid Input

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Other abnormalties(*)

Yes

Invalid Input

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Cervical Cancer

Cervical Cancer Screening*(*)

Yes

Invalid Input

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HIV

Long term health conditions

NoYes Invalid Input

HIV Test*(*)

NoYes

Invalid Input

Other abnomality

Yes

Invalid Input

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Long Term Health Issues(Chronic)

Screened for hypertension(*)

Yes

Invalid Input

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Screened for diabetes(*)

Yes

Invalid Input

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Hypertensions - New Patient(*)

YesNo

Invalid Input

Diabetes - New Patient(*)

YesNo

Invalid Input

TB screening

Cough

NoYes Invalid Input

Weight loss

NoYes Invalid Input

Hot body/fever

NoYes Invalid Input

Night sweats

NoYes Invalid Input

Capture notes for TB screening?

NoYes Invalid Input

Deworming (Foundation and intermediate)

deworming - Mebendazole(*)

GivenNot Given

Invalid Input

Capture notes for deworming?

NoYes Invalid Input

Immunisation

Given

NoYes Invalid Input

6 YR TD

NoYes Invalid Input

12 YR TD

NoYes Invalid Input

Missing from RTHB

NoYes Invalid Input

Capture notes for immunisations?

NoYes Invalid Input

Minor ailments (skin conditions/head lice)

Minor ailments observed

NoYes Invalid Input

Capture notes for minor ailments

NoYes Invalid Input

Anaemia screening

Pallor

NoneMildSevere Invalid Input

HB-if pallor present(g/dl)

Invalid Input

Capture notes for aneamia screening?

NoYes Invalid Input

Sexual and reproductive health counselling (intermediate only)

Advice on menstruation

NoYes Invalid Input

Advice on medical male circumsion

NoYes Invalid Input

Contraception

NoYes Invalid Input

Capture notes for sexual and reproductive health?

NoYes Invalid Input

Mental Health

Mental Health(*)

NoYes

Invalid Input

Capture notes for mental health?

NoYes Invalid Input

Reason / Summary of consultant(*)

Please give a reason or enter a summary!

Did you refer the patient?(*)

Yes

Invalid Input

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AntiSPAM Measure(*)

Invalid Input