i-base

Clinic forms

Generic versions of clinic forms developed by i-Base and the Royal Free Centre for HIV Medicine. Some forms have space for patient stickers and for a hospital or clinic logo from your own clinic or health Trust. If you have any difficulty with these forms, or would like help adapting them for your Trust, please contact i-Base.

New patient first visit

New patient first visit PDF Six-page document for recording more detailed notes when seeing a patient for the first visit. The 2014 update is especially important for including a wider category of gender options in order to ensure transgender patients …

Adherence support chart and side effects diary

Adherence support chart and side effects diary PDF Double-sided sheet for patients to record when they have taken their medication and on the reveres side a side effects diary, Adherence support chart PDF Single-sided sheet for patients to record when …

CD4 and viral load chart

CD4 and viral load chart PDF Single-sided sheet for patients to graph their CD4 and viral load results, and to explain when to start treatment. This is a generic version of a clinic form developed by i-Base and the Royal …

Cardiovascular risk

Cardiovascular risk PDF Single-sided sheet for recording a patients cardiovascular risk factors.

Hepatitis record sheet

Hepatitis record sheet PDF Single-sided sheet for recording hepatitis A/B/C status annually.

Day case

Day case PDF Single-sided sheet for recording patient notes when seen as a day case.

Patient update

Patient update PDF Single-sided annual summary including lab results.

Summary patient notes

Summary patient notes PDF Single-sided sheet summarising changes in ARV treatment. Revised Apr 08

Ethnic monitoring

Ethnic monitoring PDF 2-sided sheet for collecting voluntary information about patient ethnicity.