Generated Narrative: Questionnaire HIV.E1CaptureOrUpdateMotherSHistory Language: en Profiles: Extractable Questionnaire - StructureMap, CRMI Shareable Questionnaire, CRMI Publishable Questionnaire LinkID Text Cardinality Type Flags Description & Constraints Questionnaire for capture or update mother's history Questionnaire http://smart.who.int/hiv/Questionnaire/HIV.E1CaptureOrUpdateMotherSHistory#0.4.4 #xD; HIV.E.DE1 Pregnant woman's first name 0..1 string #xD; HIV.E.DE2 Pregnant woman's surname 0..1 string #xD; HIV.E.DE3 Pregnant woman's unique ID 0..1 string #xD; HIV.E.DE4 Antenatal care number 0..1 string #xD; HIV.E.DE5 Gestational age 1..1 integer #xD; HIV.E.DE6 Source of gestational age 1..1 choice Value Set: #HIV.E.DE6 #xD; HIV.E.DE10 Expected date of delivery (EDD) 1..1 date #xD; HIV.E.DE11 Number of pregnancies (gravida) 1..1 integer #xD; HIV.E.DE12 Number of previous pregnancies 1..1 integer #xD; HIV.E.DE13 Number of miscarriages and/or abortions 1..1 integer #xD; HIV.E.DE14 Number of live births 1..1 integer #xD; HIV.E.DE15 Number of caesarian sections 1..1 integer #xD; HIV.E.DE16 Number of stillbirths 1..1 integer #xD; HIV.E.DE17 Past pregnancy complications 0..1 choice Value Set: #HIV.E.DE17 #xD; HIV.E.DE35 Other past pregnancy problems (specify) 0..1 string #xD; HIV.E.DE36 Parity 1..1 integer #xD; HIV.E.DE37 Pregnancy in HIV-infected woman 0..1 boolean #xD; HIV.E.DE38 Date new pregnancy of HIV-positive woman identified 0..1 date #xD; HIV.E.DE39 ANC contact during pregnancy 0..1 boolean #xD; HIV.E.DE40 Date of first ANC visit 0..1 date #xD; HIV.E.DE41 Timing of ART initiation 0..1 choice Value Set: #HIV.E.DE41 #xD; HIV.E.DE45 Maternal use of recommended ART regimen 0..1 boolean #xD; HIV.E.DE46 Delivery date 1..1 date #xD; HIV.E.DE47 Pregnancy outcome 0..1 choice Value Set: #HIV.E.DE47 #xD; HIV.E.DE52 Delivery mode 0..1 choice Value Set: #HIV.E.DE52 #xD; HIV.E.DE56 Indications for caesarian section (C/S) 0..1 string #xD; HIV.E.DE57 Obstetric complications 0..1 string #xD; HIV.E.DE58 Live birth 0..1 boolean #xD; HIV.E.DE59 Live birth to an HIV-positive woman 0..1 boolean #xD; HIV.E.DE60 Gestational age at birth 0..1 integer #xD; HIV.E.DE61 Small for gestational age (SGA) 0..1 boolean #xD; HIV.E.DE62 Preterm birth status 0..1 choice Value Set: #HIV.E.DE62 #xD; HIV.E.DE66 Maternal ART start date 0..1 date #xD; HIV.E.DE67 Place of delivery 1..1 choice Value Set: #HIV.E.DE67 #xD; HIV.E.DE71 Other (specify) 0..1 string #xD; HIV.E.DE72 Delivery facility 0..1 string #xD; HIV.E.DE73 Date of miscarriage or abortion 0..1 date #xD; HIV.E.DE76 Infant's first name 1..1 string #xD; HIV.E.DE77 Infant's surname 1..1 string #xD; HIV.E.DE78 Infant's unique ID 1..1 string #xD; HIV.E.DE79 Mother's first name 0..1 string #xD; HIV.E.DE80 Mother's surname 0..1 string #xD; HIV.E.DE81 Mother's unique ID 0..1 string #xD; HIV.E.DE82 Caregiver's first name 0..1 string #xD; HIV.E.DE83 Caregiver's surname 0..1 string #xD; HIV.E.DE84 Caregiver's unique identifier 0..1 string #xD; HIV.E.DE85 ANC contact date 1..1 dateTime #xD; HIV.E.DE86 Referral 1..1 boolean #xD; HIV.E.DE87 Infant date of birth 0..1 date #xD; HIV.E.DE88 Date of birth of infant unknown 0..1 boolean #xD; HIV.E.DE89 Estimated age of infant 0..1 integer #xD; HIV.E.DE90 Age of infant 0..1 integer #xD; HIV.E.DE91 Gender of infant 1..1 choice Value Set: #HIV.E.DE91 #xD; HIV.E.DE113 Key population member 0..1 boolean #xD; HIV.E.DE114 Key population member type 0..1 choice Value Set: #HIV.E.DE114 #xD; HIV.E.DE134 Taking iron and folic acid (IFA) tablets 0..1 boolean #xD; HIV.E.DE135 Amount of iron prescribed 0..1 integer #xD; HIV.E.DE136 Type of iron supplement dosage provided 0..1 choice Value Set: #HIV.E.DE136 #xD; HIV.E.DE139 Amount of daily dose of folic acid prescribed 0..1 integer #xD; HIV.E.DE141 Maternal HIV status 0..1 choice Value Set: #HIV.E.DE141 #xD; HIV.E.DE145 Maternal HIV status at first ANC visit 0..1 choice Value Set: #HIV.E.DE145 #xD; HIV.E.DE155 Signs of substantial risk of HIV infection 1..1 choice Value Set: #HIV.E.DE155 #xD; HIV.E.DE160 Serodiscordant partner 0..1 boolean #xD; HIV.E.DE161 Date woman received counselling for CPT 0..1 date #xD; HIV.E.DE162 Date woman received counselling for TPT 0..1 date #xD; HIV.E.DE173 Maternal and child health service visit 0..1 choice Value Set: #HIV.E.DE173 #xD; HIV.E.DE177 Weeks postpartum 0..1 integer #xD; HIV.E.DE243 Timing of additional infant HIV test 0..1 integer #xD; HIV.E.DE244 Date of sample collection of additional infant HIV test 0..1 date #xD; HIV.E.DE245 Haemoglobin (Hb) result 0..1 integer #xD; HIV.E.DE246 Blood group and Rh factor 0..1 choice Value Set: #HIV.E.DE246 #xD; HIV.E.DE255 Asymptomatic bacteriuria (ASB) test result 0..1 choice Value Set: #HIV.E.DE255 #xD; HIV.E.DE259 Urine protein test result 0..1 choice Value Set: #HIV.E.DE259 #xD; HIV.E.DE264 Type of hypertensive disorder 0..1 choice Value Set: #HIV.E.DE264 #xD; Documentation for this format
Questionnaire for capture or update mother's history
Date new pregnancy of HIV-positive woman identified
Taking iron and folic acid (IFA) tablets
Amount of daily dose of folic acid prescribed
Signs of substantial risk of HIV infection
Date of sample collection of additional infant HIV test
Asymptomatic bacteriuria (ASB) test result