Disability Examination Worksheets
HIV-Related Illness
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A. Review of Medical Records: B.
Medical History (Subjective Complaints):
Comment On:
- Recurrent opportunistic infections - type.
- Constitutional symptoms - recurrent, refractory, any currently present.
- Diarrhea.
- Debility.
- Progressive weight loss.
- Other symptoms - lymphadenopathy, fever, cough, dyspnea, headaches, difficult or painful swallowing, vision loss, etc.
- Periods of remissions in symptomatology - frequency, average duration, date of last remission.
- Depression or memory loss.
- Treatment - type, duration, response, side effects. Is this an approved medication?
- Describe the effects of the condition on the veteran's usual
occupation and daily activities.
- History of hospitalization or surgery, reason or type of surgery, dates and location, if known.
- History of malignant neoplasm.
- Date of diagnosis.
- Diagnosis.
- Types of treatment, dates.
- Last date of treatment.
C. Physical Examination (Objective Findings):
Address each of the following and fully
describe, follow additional worksheets as appropriate:
- Secondary diseases affecting multiple body systems Describe.
- HIV-related illnesses. Describe.
- Neoplasm related to HIV-related illness. Describe.
- Hairy cell leukoplakia.
- Oral candidiasis.
- Side effects from the use of HIV-related medications. Describe.
- Lymphadenopathy.
- Hepatomegaly.
- Splenomegaly.
- If evidence of memory loss or depression (refer for examination by mental health provider).
D. Diagnostic and Clinical Tests:
Provide:
- T4 Cell counts.
- Include results of all diagnostic and clinical tests conducted
in the examination report.
E. Diagnosis:
- Definitive diagnosis of AIDS. (Use CDC Definition.)
- Active opportunistic infection or neoplasm.
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Reviewed/Updated Date:
May 1, 2007
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