LAMIS 3.0

Hospital Number

Unique ID

Date of Registration/Transfer-In

Surname

Other Names

Date of Birth

Age at Registration

Gender

Marital Status

Job/Occupation Status

Educational Level

State of residence

LGA of residence

Address

Telephone

Care Entry Point

Date of Confirmed HIV Test

Time of HIV Diagnosis:

Date enrolled into PMTCT:

Source of Referral:

Enrollment Setting

HIV Status at Registration

TB Status

Pregnancy Status

Next of kin/Treatment Supporter

Name

Relationship

Address

Telephone

New Hospital No