Does the participant currently have, or have they [ ] 1. YES, Please specify had in the past, any kidney disease, diabetes, hypertension or Thyroid? [ ] 2. NO [ ] 98. Unsure/don’t know Please note dates of illness/disease, date of diagnosis, and conditions as well as any courses of treatment: Is the participant currently taking any [ ] 1. YES medications, including PrEP and including [ ] 2. NO traditional or alternative medications? Current medications. DO NOT include medications prescribed at this If yes, what medications? Are you allergic to any medications? [ ] 1. YES [ ] 2. NO [ ] 98. Unsure/don’t know If yes, please indicate the name/s Last menstrual period (date: day/month/year) _ _/_ _/_ _ If day or month not known, list 99 Test results
Does the participant currently have, or have they had in the past, any kidney disease, diabetes, hypertension or Thyroid? [ ] 1. YES, Please specify [ ] 2. NO [ ] 98. Unsure/don’t know Please note dates of illness/disease, date of diagnosis, and conditions as well as any courses of treatment: Is the participant currently taking any medications, including PrEP and including traditional or alternative medications? [ ] 1. YES [ ] 2. NO Current medications. DO NOT include medications prescribed at this If yes, what medications? Are you allergic to any medications? [ ] 1. YES [ ] 2. NO [ ] 98. Unsure/don’t know If yes, please indicate the name/s Last menstrual period (date: day/month/year) If day or month not known, list 99 _ _/_ _/_ _ Test results
ashodaya_screening_visit.docx