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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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