Middle Initial

Specialty

Affiliation

Business Address 2

Business Fax

What is your medical specialty?
Internal Medicine Infectious Diseases Surgery Pediatrics Obstetrics/Gynaecology Other [CHOOSE ONE]

Where do you practice medicine?
Private Sector       Public Sector

What percentage of your patients is living with HIV/AIDS?
<10% 10-20% 20-30% 30-40% 40-50% 50-60% 60-70% 70-80% 80-90% 90-100% [CHOOSE ONE]

Have you received training in HIV medicine?
Yes No [CHOOSE ONE]

How many years have you practiced HIV medicine?
</=1 Yr 2-4 years 5-7 years 8-10 years > 10 years [CHOOSE ONE]

Have you received training specific to the prescription of antiretroviral therapy? Yes No [CHOOSE ONE]

How many years have you prescribed antiretroviral therapy?
</= 1 year 2-4 years 5-7 years 8-10 years [CHOOSE ONE]

What percentage of your patients is on antiretroviral therapy?
<10% 10-20% 20-30% 30-40% 40-50% 50-60% 60-70% 70-80% 80-90% 90-100% [CHOOSE ONE]

What percentage of your patients are women of child-bearing age (ages 15-44)? <10% 10-20% 20-30% 30-40% 40-50% 50-60% 60-70% 70-80% 80-90% 90-100% [CHOOSE ONE]

What percentage of your patients are children or adolescents (ages 0-18)? <10% 10-20% 20-30% 30-40% 40-50% 50-60% 60-70% 70-80% 80-90% 90-100% [CHOOSE ONE]

What percentage of your patients is coinfected with tuberculosis (TB)? <10% 10-20% 20-30% 30-40% 40-50% 50-60% 60-70% 70-80% 80-90% 90-100% [CHOOSE ONE]

Online Credit Card Payment
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Electronic / Wire Transfer (to follow)