This is the first page of a comprehensive intake form that is currently being finalized. Subsequent sections of this form collect information on the results of clinical, laboratory, and radiographic investigations; previous diagnoses; previous treatment with ART or anti-TB drugs; previous adverse effects; known allergies; and social history and socioeconomic status, including living conditions, employment, education, mode and ease of transport to the clinic, and activities of daily living. A different form is used for follow-up visits and collects information on treatment status, adherence issues, adverse events from medications, and any changes to the treatment regimen. Both forms will be available at http://www.pih.org.