Call date

Phone contact

Caller name

Sex	MALE FEMALE

Age	10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Above 24

Schooling	IS OS

Education	NONE PRIMARY O LEVEL A LEVEL TERTIARY

Marital status	MARRIED SINGLE SEPARATED WIDOWED DIVORCED NO RESPONSE

Employment status	YES NO

District	KAMPALA MUKONO WAKISO MPIGI KAYUNGA LUWERO BUTAMBALA NAKASEKE GOMBA OTHERS

Village

Living with	SINGLE PARENTS BOTH PARENTS GRAND PARENTS GUARDIAN ALONE/SELF AUNT UNCLE BROTHER SISTER BOY FRIEND GIRL FRIEND FRIEND WIFE HUSBAND

Heard about us	PEERS PARENTS GUARDIAN HEALTH WORKER OUTREACH EMPLOYER NEWS PAPER RADIO TV FRIEND IEC MATERIALS OTHERS

Heard about phone	PEERS PARENTS/GUARDIAN HEALTH WORKER OUTREACH EMPLOYER NEWS PAPER RADIO TV

User initial

Problem description

*	Problem	Category

Action taken	COUNSEL REFER BOTH

If referred; Specify referral centre

AIC NTIHC BUTABIKA HOSPITAL CHINA-UG FRIENDSHIP HOSP KADIC CLINIC KAMPALA DISPENSARY KIBULI HOSPITAL KISWA HEALTH CENTRE KISWA TB CLINIC LUBAGA HOSPITAL MENGO HOSPITAL MILDMAY MULAGO ASSESSMENT CENTRE MULAGO DENTAL CLINIC MULAGO ENT CLINIC MULAGO EYE CLINIC MULAGO MAIN HOSPITAL MULAGO SICKLE CELL CLINIC MULAGO SKIN CLINIC MULAGO STD CLINIC MULAGO SURGICAL OPD MULAGO TB MANAGEMENT MULAGO ULTRA SCAN NSAMBYA REACHOUT MBUYA TASO POLICE

Specify service referred for

ABDOMINAL PAIN ABNORMAL VAGINAL DISCHARGE ANTE-NATAL CARE ART SERVICES C-C SCREENING-INITIAL C-C VIA SUSPICIOUS FOR CANCER CONSTIPATION FAMILY PLANNING GBV-EMERGENCY CONTRACEPTION GBV-PEP GBV-STI TREATMENT GENITAL ITCHYING GENITAL ULCER HERPES SIMPLEX HERPES ZOSTA HIV/AIDS INFERTILITY ITCHING IN GENITAL JOINT PAINS LOWER ABDOMINAL PAIN MALARIA OTHERS PAINFUL GENITALS PEP POST- ABORTION CARE POST-NATAL CARE PREGNANCY TESTING SKIN PROBLEM SORE THROAT SWELLING IN GENITALS SYPHILLIS URETHRAL DISCHARGE URINARY TRACT INFECTION VAGINAL DISCHARGE

Reason for refer