HIV TESTING

The Department of Health (DOH) has an existing program for the prevention and control of the Human Immunodeficiency Virus (HIV) in the
Philippines. The Epidemiology Bureau (EB) of DOH is mandated by Republic Act 11166 & 11332 to collect information that will be used in
planning activities to help stop the spread of HIV and to support and treat those diagnosed with HIV. Your full cooperation is very important
to this program. Please answer all questions as honestly as possible.

ABOUT THE TEST

What is HIV testing?

An HIV test refers to a procedure used to identify if you have antibodies to HIV -- the virus that causes AIDS. A specimen, usually blood, and a DOH-Food and Drug
Administration (FDA)-registered diagnostic kit is needed to perform the test. The test may be performed by a trained/supervised healthcare worker or lay person, or by
oneself, depending on the modality.

If the first test (screening) is reactive, another test (confirmatory) will be done to make sure that the first test is confirmed to be positive. A positive test means you have
been infected with HIV. A non-reactive or negative test means you are not infected or your body has not produced the sufficient level of antibodies (within window period)
that can be detected by the HIV rapid diagnostic test kits. If you are non-reactive or negative, and had a recent exposure within the window period, you need to undergo
another test 4 weeks after your risk exposure.

Confidentiality of HIV Testing

Your personal information and HIV test result is confidential adherent to the provisions of RA 11166 Philippine HIV and AIDS Policy Act, RA 10173 Data Privacy Act of
2012 and its IRR of 2016.

INFORMED CONSENT
I, CLIENT / CHILD / PROXY CONSENT PROVIDER, was given Verbal Consent
(applicable for clients 15
information about HIV, its testing process, and was able to ask D y/o and above undergoing
questions about HIV. I agree to undergo HIV testing. either CBS or self-testing)
Name and Signature
By providing my contact details, I am allowing the HTS provider to contact me on
Contact Number:
updates regarding the services provided including but not limited to: test result,
combination prevention services, and notification for retesting. Email address:
PERSONAL INFORMATION SHEET (HTS FORM)
All information given will be STRICTLY CONFIDENTIAL. Please fill out this form COMPLETELY and as honestly as possible. Please
write in CAPITAL LETTERS and CHECK the appropriate boxes.
l•;;;;a ,ue r-••i•• •·· .
Test Date: [I] [I] III II
I I I I I I I I I- □
1
Month Day Year

2 PhilHealth Number: [I] - I □ Not enrolled in PhilHealth

3 PhilSys Number: I I □ No PhilSys Number

Name (Full name)

4
I First Name
I I Middle Name
I I Last Name
I I
Suffix (Jr, Sr, Ill, etc)
First 2 letters of mother's FIRST name First 2 letters of father's FIRST name Birth order (i.e. imrg i
other's children)

[I] [I]
5

6 Birth date: [I] [I]

Month Day
III II Year
Age: [I] Age in months (for less than 1 year old):

7 Sex (assigned at birth): □ Male D Female Gender identity: □ Man D Woman D Others:
Current Place of Residence: City/Municipality: Province:
8 Permanent Residence: City/Municipality: Province:
Place of Birth: City/Municipality: Province:

9 Nationality: D Filipino □ Other, please specify:

10 Civil Status: □ Single □ Married □ Separated □ Widowed D Divorced

11 Are you currently living with a partner? □ No □ Yes Number of children: [I]
12 Are you currently pregnant? (for female clients only) □ No □ Yes
l•■■-i.•■•••�•-;'11le • i.w■1e
Highest Education Attainment? □ No grade completed □ Pre-school □ Highschool □ Vocational
13
□ Elementary □ College □ Post-Graduate
14 Are you currently in school? □ No □ Yes
Are you currently working?
15 □ Yes. Current occupation (main source of income):
□ No. Previous occupation in the past 12 months:
Did you reside or work overseas/abroad in the past 5 years? □ No □ Yes
16
Did you work overseas/abroad?
Where were you based?
□ No
D On a ship
□ Yes, specify year of return from last contract:
D Land
IIIII
What country did you last work in? (For seafarer, last port of exit)

PERSONAL INFORMATION SHEET (HTS FORM 2021)

 How many sex partners in the past 12 months?
HIV TESTING

..
You ma answer this on our own or with assistance from a counselor or healthcare rovider

Answer all. Please check the appropriate column for each item, and provide history of risk if applicable.
Did your birth mother have HIV when you were born? D Do not know D No D Yes

History of sexual activity Date of most recent Date of most recent

(oral/anal/vaginal) anal or neolvaginal sex CONDOMLESS anal or
(MM/YYYY) neolvaginal sex (MM/YYYY)
No Yes
Sex with a MALE* □ □
Sex with a FEMALE** □ □
•sex partners whose assigned sex at birth is MALE, including transgender and/or nonbinary
17 ..Sex partners whose assigned sex at birth is FEMALE, including transgender and/or nonbinary

Date of most recent

□□□□
No Yes
risk (MM/YYYY)
Paid for sex (in cash or kind) □ □
Received payment (cash or in kind) in exchange for sex □ □
Had sex under the influence of drugs □ □
Shared needles in injection of drugs □ □
□ □

Condom Use:
Received blood transfusion
Occupational exposure (needlestick/sharps) □ □
REASONS FOR HIV TESTING
Please check all that apply.

□Never □Sometimes □Always

D Possible exposure to HIV D Employment - Overseas/Abroad D Requirement for insurance
18
D Recommended by physician/nurse/midwife D Employment - Local/Philippines D Other (please specify):
_______ _
D Referred by a peer educator D Received a text message/email encouraging me to get an HIV test
PREVIOUS HIV TEST

19
Have you ever been tested for HIV before?
Which HTS provider (facility or
□ No D Yes. Date of most recent test?
Month
IIII
Year

organization) conducted the test? City/Municipality:

What was the result? D Reactive D Non-reactive D Indeterminate D Was not able to get result
To be filled out by HTS PROVIDER only
MEDICAL HISTORY & CLINICAL PICTURE
Please check all that apply.
20 D Current TB patient D Diagnosed with other ST ls □ Taken PEP
□ With hepatitis B □ □

Type of Sex: □Oral □Vaginal/Neovaginal

With hepatitis C Taking PrEP

Clinical Picture: D Asymptomatic

21 D Symptomatic Describe S/Sx:
D No physician to do staging

□Anal Inserter □Anal Receiver

Client type: D Inpatient D Walk-in/outpatient D Persons Deprived of Liberty (POL)
22 (select one) D Mobile HTS / Outreach in physical venues. Specify venue: -------------
Mode of reach: Social and sexual
23 (select all that apply) D Clinical reach D Online D Index testing D D Outreach in physical venues
network testing
D Refused HIV Testing Reason for refusal:
D Accepted HIV Testing
24 HIV testing modality: D Facility-based testing (FBT) D Non-laboratory FBT D Community-based D Self-testing
Linkage: D Refer to ART D Advise for re-testing in Months Weeks
------
(choose all that apply) Suggested date: (MM/OO/YYYY)
D Refer for Confirmatory
Other services provided to client:
D HIV101 D Condoms,# distributed: Inventory Information
Reach Venue:______

D IEC materials D Lubricants,# distributed: Brand of test kit used:

25 D Risk reduction planning D Offered social and sexual network testing (SSNT) Number of test kit used:
D Referred to PrEP or had given PEP D Accepted SSNT Test kit lot number:
D Other services: Expiration date (mm/dd/yyyy):

HTS PROVIDER DETAILS

Name of Testing Facility/Organization: SEN. GERARDO M. ROXAS MEMORIAL DISTRICT HOSPITAL

26 Complete Mailing Address: BALUCUAN,DAO,CAPIZ
Contact Numbers: (036)658-000-37 Email address: sgmrmdh@yahoo.com

27
Primary HTS provider: (select one) / HIV Counsellor
D □ Medical Technologist D CBS Motivator D Others:

Name & Signature of service provider: DAPHNY FAITH F. DAYAL, RN

END

PERSONAL INFORMATION SHEET (HTS FORM 2021)