DVBCWHI3.m

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

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---DVBCWHI3   2472     printed  Mar 13, 2025@20:56:27                                                                                                                                                                                                    Page 2

DVBCWHI3  ;ALB/RLC HIV-RELATED ILLNESS WKS TEXT - 1 ; 12 FEB 2007

 +1       ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9

 +2       ;

 +3       ;

TXT       ;

 +1       ;;A.  Review of Medical Records:

 +2       ;;

 +3       ;;B.  Medical History (Subjective Complaints):

 +4       ;;

 +5       ;;    Comment On:

 +6       ;;

 +7       ;;    1.  Recurrent opportunistic infections - type.

 +8       ;;    2.  Constitutional symptoms - recurrent, refractory, any currently present.

 +9       ;;    3.  Diarrhea.

 +10      ;;    4.  Debility.

 +11      ;;    5.  Progressive weight loss.

 +12      ;;    6.  Other symptoms - lymphadenopathy, fever, cough, dyspnea, headaches,

 +13      ;;        difficult or painful swallowing, vision loss, etc.

 +14      ;;    7.  Periods of remissions in symptomatology - frequency, average duration,

 +15      ;;        date of last remission.

 +16      ;;    8.  Depression or memory loss.

 +17      ;;    9.  Treatment, type duration, response, side effects.  Is this an approved

 +18      ;;        medication?

 +19      ;;    10. Describe the effects of the condition on the veteran's usual 

 +20      ;;        occupation and daily activities.

 +21      ;;    11. History of hospitalizations or surgery, reason or type of surgery,

 +22      ;;        dates and location, if known.

 +23      ;;    12. History of malignant neoplasm.

 +24      ;;

 +25      ;;        a.  Date of diagnosis.

 +26      ;;        b.  Diagnosis.

 +27      ;;        c.  Type of treatment, dates.

 +28      ;;        d.  Last date of treatment.

 +29      ;;

 +30      ;;C.  Physical Examination (Objective Findings):

 +31      ;;

 +32      ;;    Address each of the following and fully describe, follow additional

 +33      ;;    worksheets as appropriate:

 +34      ;;

 +35      ;;    1.  Secondary diseases affecting multiple body systems.  Describe.

 +36      ;;    2.  HIV-related illnesses.  Describe.

 +37      ;;    3.  Neoplasm related to HIV-related illness.  Describe.

 +38      ;;    4.  T4 cell counts.

 +39      ;;    5.  Hairy cell leukoplakia.

 +40      ;;    6.  Oral candidiasis.

 +41      ;;    7.  Side effects from the use of HIV-related medications.  Describe.

 +42      ;;    8.  Lymphadenopathy.

 +43      ;;    9.  Hepatomegaly.

 +44      ;;    10. Splenomegaly.

 +45      ;;    11. If evidence of memory loss or depression (refer for examination by

 +46      ;;        mental health provider).

 +47      ;;

 +48      ;;D.  Diagnostic and Clinical Tests:

 +49      ;;

 +50      ;;    Provide:

 +51      ;;

 +52      ;;    1.  T4 Cell counts.

 +53      ;;    2.  Include results of all diagnostic and clinical tests conducted

 +54      ;;        in the examination report.

 +55      ;;

 +56      ;;

 +57      ;;E.  Diagnosis:

 +58      ;;

 +59      ;;    1.  Definitive diagnosis of AIDS.  (Use CDC Definition).

 +60      ;;    2.  Active opportunistic infection or neoplasm.

 +61      ;;

 +62      ;;

 +63      ;;

 +64      ;;Signature:                             Date:

 +65      ;;END