Last change
on this file since 1074 was 628, checked in by George Lilly, 15 years ago |
initial load of FOIAVistA 6/30/08 version
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[628] | 1 | DVBCWHI1 ;ALB/CMM HIV-RELATED ILLNESS WKS TEXT - 1 ; 6 MARCH 1997
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| 2 | ;;2.7;AMIE;**12**;Apr 10, 1995
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| 3 | ;
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| 4 | ;
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| 5 | TXT ;
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| 6 | ;;A. Review of Medical Records:
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| 7 | ;;
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| 8 | ;;
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| 9 | ;;
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| 10 | ;;B. Medical History (Subjective Complaints):
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| 11 | ;;
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| 12 | ;; Comment On:
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| 13 | ;; 1. Recurrent opportunistic infections.
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| 14 | ;;
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| 15 | ;;
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| 16 | ;; 2. Recurrent constitutional symptoms.
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| 17 | ;;
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| 18 | ;;
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| 19 | ;; 3. Diarrhea.
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| 20 | ;;
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| 21 | ;;
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| 22 | ;; 4. Debility.
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| 23 | ;;
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| 24 | ;;
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| 25 | ;; 5. Progressive weight loss.
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| 26 | ;;
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| 27 | ;;
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| 28 | ;; 6. Remissions in any symptomatology.
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| 29 | ;;
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| 30 | ;;
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| 31 | ;; 7. Depression or memory loss.
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| 32 | ;;
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| 33 | ;;
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| 34 | ;; 8. Treatment - Is this an approved medication?
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| 35 | ;;
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| 36 | ;;
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| 37 | ;; 9. Describe the effects of the condition on the veteran's usual
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| 38 | ;; occupation and daily activities.
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| 39 | ;;
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| 40 | ;;
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| 41 | ;;C. Physical Examination (Objective Findings):
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| 42 | ;;
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| 43 | ;; Address each of the following and fully describe:
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| 44 | ;; 1. Definitive diagnosis of AIDS. (Use CDC Definition.)
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| 45 | ;;
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| 46 | ;;
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| 47 | ;; 2. Secondary diseases affecting multiple body systems - describe.
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| 48 | ;;
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| 49 | ;;
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| 50 | ;; 3. HIV-related illnesses - describe.
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| 51 | ;;
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| 52 | ;;
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| 53 | ;; 4. Neoplasm related to HIV-related illness. Describe.
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| 54 | ;;
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| 55 | ;;
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| 56 | ;; 5. T4 cell counts.
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| 57 | ;;
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| 58 | ;;
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| 59 | ;; 6. Hairy cell leukoplakia.
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| 60 | ;;
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| 61 | ;;
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| 62 | ;; 7. Oral candidiasis.
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| 63 | ;;
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| 64 | ;;
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| 65 | ;; 8. Use of HIV-related medications.
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| 66 | ;;
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| 67 | ;;
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| 68 | ;; 9. Lymphadenopathy.
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| 69 | ;;
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| 70 | ;;
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| 71 | ;;D. Diagnostic and Clinical Tests:
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| 72 | ;;
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| 73 | ;; Provide:
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| 74 | ;; 1. T4 Cell counts.
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| 75 | ;; 2. Include results of all diagnostic and clinical tests conducted
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| 76 | ;; in the examination report.
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| 77 | ;;
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| 78 | ;;
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| 79 | ;;E. Diagnosis:
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| 80 | ;;
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| 81 | ;;
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| 82 | ;;Signature: Date:
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| 83 | ;;END
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