HIV-Related Illness

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment On:

1. Recurrent opportunistic infections - type.
2. Constitutional symptoms - recurrent, refractory, any currently present.
3. Diarrhea.
4. Debility.
5. Progressive weight loss.
6. Other symptoms - lymphadenopathy, fever, cough, dyspnea, headaches, difficult or painful swallowing, vision loss, etc.
7. Periods of remissions in symptomatology - frequency, average duration, date of last remission.
8. Depression or memory loss.
9. Treatment - type, duration, response, side effects. Is this an approved medication?
10. Describe the effects of the condition on the veteran's usual occupation and daily activities.
11. History of hospitalization or surgery, reason or type of surgery, dates and location, if known.
12. History of malignant neoplasm.

1. Date of diagnosis.
2. Diagnosis.
3. Types of treatment, dates.
4. Last date of treatment.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe, follow additional worksheets as appropriate:

1. Secondary diseases affecting multiple body systems Describe.
2. HIV-related illnesses. Describe.
3. Neoplasm related to HIV-related illness. Describe.
4. Hairy cell leukoplakia.
5. Oral candidiasis.
6. Side effects from the use of HIV-related medications. Describe.
7. Lymphadenopathy.
8. Hepatomegaly.
9. Splenomegaly.
10. If evidence of memory loss or depression (refer for examination by mental health provider).

D. Diagnostic and Clinical Tests:

Provide:

1. T4 Cell counts.
2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. Definitive diagnosis of AIDS. (Use CDC Definition.)
2. Active opportunistic infection or neoplasm.

Signature:

Date: