Form Dhcs 7035 A - California Medical Report On Adult With Allegation Of Human Immunodeficiency Virus Infection - Health And Human Services Agency Page 4
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5SECTION C (continued)
❒
❒
21.
Hepatitis, resulting in chronic liver disease
31.
Other Neurological Manifestations of HIV
manifested by appropriate findings, (e.g., persistent
Infection, (e.g., peripheral neuropathy), with
ascites, bleeding esophageal varices, hepatic
significant and persistent disorganization of motor
encephalopathy)
function in two extremities resulting in sustained
disturbance of gross and dexterous movements, or
M
N
:
ALIGNANT
EOPLASMS
gait and station
❒
22.
Carcinoma of the Cervix, invasive, FIGO stage II
HIV W
S
:
ASTING
YNDROME
and beyond
❒
32.
HIV Wasting Syndrome, characterized by
❒
23.
Kaposi’s Sarcoma, with extensive oral lesions; or
involuntary weight loss of ten percent or more of
involvement of the gastrointestinal tract, lungs, or
baseline (or other significant involuntary weight loss)
other visceral organs; or involvement of the skin or
and, in the absence of a concurrent illness that could
mucous membranes with extensive fungating or
explain the findings, involving: chronic diarrhea with
ulcerating lesions not responding to treatment
two or more loose stools daily lasting for one month or
longer; or chronic weakness and documented fever
❒
24.
Lymphoma, of any type, (e.g., primary lymphoma of
o
o
greater than 38
C (100.4
F) for the majority of
the brain, Burkitt’s lymphoma, immunoblastic
one month or longer
sarcoma, other non-Hodgkin’s lymphoma, Hodgkin’s
disease)
D
:
IARRHEA
❒
❒
25.
Squamous Cell Carcinoma of the Anus
33.
Diarrhea, lasting for one month or longer, resistant to
treatment, and requiring intravenous hydration,
S
M
M
:
KIN OR
UCOUS
EMBRANES
intravenous alimentation, or tube feeding
❒
26.
Conditions of the Skin or Mucous Membranes,
C
:
ARDIOMYOPATHY
with extensive fungating or ulcerating lesions not
❒
responding to treatment, (e.g., dermatological
34.
Cardiomyopathy (chronic heart failure, or cor
conditions such as eczema or psoriasis,
pulmonale, or other severe cardiac abnormality not
vulvovaginal or other mucosal candida, condyloma
responsive to treatment)
caused by human papillomavirus, genital ulcerative
N
:
EPHROPATHY
disease)
❒
35.
Nephropathy, resulting in chronic renal failure
H
A
:
EMATOLOGIC
BNORMALITIES
❒
I
R
T
R
NFECTIONS
ESISTANT TO
REATMENT OR
EQUIRING
27.
Anemia (hematocrit persisting at 30 percent or
H
I
T
T
OSPITALIZATION OR
NTRAVENOUS
REATMENT
HREE OR
less), requiring one or more blood transfusions on
M
T
O
Y
:
ORE
IMES IN
NE
EAR
an average of at least once every two months
❒
36.
Sepsis
❒
28.
Granulocytopenia, with absolute neutrophil counts
❒
3
repeatedly below 1,000 cells/mm
and documented
37.
Meningitis
recurrent systemic bacterial infections occurring at
❒
least three times in the last five months
38.
Pneumonia (non-PCP)
❒
❒
29.
Thrombocytopenia, with platelet counts repeatedly
39.
Septic Arthritis
3
below 40,000/mm
with at least one spontaneous
❒
40.
Endocarditis
hemorrhage, requiring transfusion in the last five
months; or with intracranial bleeding in the last 12
❒
41.
Sinusitis, radiographically documented
months.
N
A
:
EUROLOGICAL
BNORMALITIES
❒
30.
HIV Encephalopathy, characterized by cognitive or
motor dysfunction that limits function and
progresses
NOTE:
If you have checked any of the boxes in Section C, proceed to Section E to add any remarks you wish to make about this patient’s
condition. then proceed to Sections F and G and sign and date the form.
If you have not checked any of the boxes in Section C, please complete Section D. See Part VI of the Instruction Sheet for definitions of the
terms we use in Section D. Proceed to Section E if you have any remarks you wish to make about this patient’s condition. Then, proceed to
Sections F and G and sign and date the form.
Page 2 of 3
DHCS 7035 A (06/07)
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