source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWHI3.m@ 628

DVBCWHI3 ;ALB/RLC HIV-RELATED ILLNESS WKS TEXT - 1 ; 12 FEB 2007
 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
 ;
 ;
TXT ;
 ;;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 hospitalizations or surgery, reason or type of surgery,
 ;;        dates and location, if known.
 ;;    12. History of malignant neoplasm.
 ;;
 ;;        a.  Date of diagnosis.
 ;;        b.  Diagnosis.
 ;;        c.  Type of treatment, dates.
 ;;        d.  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.  T4 cell counts.
 ;;    5.  Hairy cell leukoplakia.
 ;;    6.  Oral candidiasis.
 ;;    7.  Side effects from the use of HIV-related medications.  Describe.
 ;;    8.  Lymphadenopathy.
 ;;    9.  Hepatomegaly.
 ;;    10. Splenomegaly.
 ;;    11. 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:
 ;;END