Form Dhcs 7035 A - California Medical Report On Adult With Allegation Of Human Immunodeficiency Virus Infection - Health And Human Services Agency Page 5

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D.
OTHER MANIFESTATIONS OF HIV INFECTION:
1. Repeated Manifestions of HIV Infection, including diseases mentioned in Section C, Items 1–41, but without the specified findings
described above, or other diseases, resulting in significant, documented symptoms or signs, (e.g., fatigue, fever, malaise, weight
loss, pain, night sweats). Please specify:
a. The manifestations your patient has had;
b. The number of episodes occurring in the same one-year period; and
c. The approximate duration of each episode.
Remember, your patient need not have the same manifestation each time to meet the definition of repeated manifestations; but, all
manifestations used to meet the requirement must have occurred in the same one-year period. (See attached instructions for the
definition of “repeated manifestations.”)
If you need more space, please use Section E:
NUMBER OF EPISODES IN
DURATION
MANIFESTATIONS
THE SAME ONE-YEAR PERIOD
OF EACH EPISODE
EXAMPLE: Diarrhea
3
1 month each
AND
2. Any of the Following:
❒
Marked restriction of Activities of Daily Living; or
❒
Marked difficulties in maintaining Social Functioning; or
❒
Marked difficulties in completing tasks in a timely manner due to deficiencies in Concentration, Persistence, or Pace.
E.
REMARKS (Please use this space if you lack sufficient room in Section D or to provide any other comments you wish about your
patient.):
F.
MEDICAL SOURCE INFORMATION
:
(Please Print or Type)
Name
Street Address
City
State
ZIP Code
Telephone Number (Include Area Code)
Date
(
)
I declare under penalty of perjury under the laws of the United States of America and the State of California, that the information
contained in this medical report is true and correct.
G. SIGNATURE AND TITLE OF PERSON COMPLETING THIS FORM
:
(e.g., physician, R.N.)
➤
FOR OFFICIAL USE ONLY
❒
❒
COUNTY OFFICE DISPOSITION:
DISABILITY EVALUATION DIVISION DISPOSITION:
Page 3 of 3
DHCS 7035 A (06/07)

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