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Date | _ || _ | . | _ || _ | . | _ || _ || _ || _ |PMTCT N° …………………………….Mother and child follow-upFrom D1 to M2D | _ | - W | _ | - M | _ |Form completed by: ………………………………………………………………………………MotherDate of first VCT session | _ || _ || . | _ || _ | . | _ || _ || _ || _ |1- Clinical data and treatment1.1. Has the mother been hospitalised since last contact? □ yes □ no1.2. If yes, specify reason and dates: …………………………………………………………………………..……………………………………………………………………………………………………………………….1.3. Is the woman receiving the following treatments?1.3.1. Nevirapine □ yes □ no1.3.2. Antiretroviral for herself □ yes □ noSpecify …………………………………………………………………………….1.3.3. Cotrimoxazole □ yes □ noIf yes to cotrimoxazole: since when? | _ || _ || . | _ || _ | . | _ || _ || _ || _ |1.4 Has the woman been clinically evaluated ? □ yes □ noIf yes, which stage ? □ I □ II □ III □ IV2- Clinical staging criteria2.1. History (verbal/from hand held record card of mother):Stage Two• Weight loss in last 6 months but 1 month □ yes □ no• Fever >1 month □ yes □ no• PTB within last 1 year □ yes □ no• Severe bacterial infections (pneumonia, pyomyositis) □ yes □ no• Bedridden 10% of body weight □ yes □ noStage four392