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Date | _ || _ | . | _ || _ | . | _ || _ || _ || _ |PMTCT N° …………………………….Maternity dischargeForm completed by: ………………………………………………………………………………Clinical staging criteria1. History (verbal/from hand held record card of mother):Stage TwoWeight loss in last 6 months but 1 month □ yes □ noFever >1 month □ yes □ noPTB within last 1 year □ yes □ noSevere bacterial infections (pneumonia, pyomyositis) □ yes □ noBedridden 10% of body weight □ yes □ noStage fourExtra-pulmonary TB □ yes □ no“HIV Wasting Syndrome” □ yes □ noMucocutaneous Herpes >1 month □ yes □ noHIV encephalopathy □ yes □ noBedridden >50% of the day in last 1 month □ yes □ no2. Physical examination:Stage twoMinor mucocutaneous manifestations (eg. seborrhoeic dermatitis, prurigo, fungal nail infectionsrecurrent oral ulcers, angular cheilitis) □ yes □ noStage threeOral candidiasis □ yes □ noOral hairy leukoplakia □ yes □ noStage fourPresence of Stage Four illnesses i.e “AIDS?” □ yes □ noOverall clinical stage of woman □ I □ II □ III □ IVCotrimoxazole prescribed □ yes □ no391