Form Dhcs 7035 C - California Medical Report On Child With Allegation Of Human Immunodeficiency Virus Infection - Health And Welfare Agency Page 5
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6NOTE:
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.
D.
OTHER MANIFESTATIONS OF HIV INFECTION:
1.
Any Manifestations of HIV Infection Including Any Diseases Listed in Section C, Items 1–47, but without the specified findings described
above, or any other manifestations of HIV infection; please specify type of manifestation(s):
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
AND
2.
Any of the Following Functional Limitation(s), Complete Only the Items for the Child’s Present Age Group:
a.
Birth to Attainment of Age One—Any of the following:
(1)
Cognitive/Communicative Functioning generally acquired by children no more than one-half the child’s chronological age, (e.g., in
infants birth to six months, markedly diminished variation in the production or imitation of sounds and severe feeding abnormality,
such as problems with sucking, swallowing, or chewing); or
(2)
Motor Development generally acquired by children no more than one-half the child’s chronological age; or
(3)
Apathy, Over-Excitability, or Fearfulness, demonstrated by an absent or grossly excessive response to visual stimulation,
auditory stimulation, or tactile stimulation; or
(4)
Failure to Sustain Social Interaction on an ongoing, reciprocal basis as evidenced by inability by six months to participate in vocal,
visual, and motoric exchanges (including facial expressions); or failure by age nine months to communicate basic emotional
responses, such as cuddling or exhibiting protest or anger; or failure to attend to the caregiver’s voice or face or to explore an
inanimate object for a period of time appropriate to the infant’s age; or
(5)
Attainment of Development or Function generally acquired by children no more than two-thirds of the child’s chronological age in
two or more areas (i.e., cognitive/communicative, motor, and social).
b.
Age One to Attainment of Age Three—Any of the following:
(1)
Gross or Fine Motor Development at a level generally acquired by children no more than one-half the child’s chronological age; or
(2)
Cognitive/Communicative Function at a level generally acquired by children no more than one-half the child’s chronological age;
or
(3)
Social Function at a level generally acquired by children no more than one-half the child’s chronological age; or
(4)
Attainment of Development or Function generally acquired by children no more than two-thirds of the child’s chronological age in
two or more areas covered by 1, 2, or 3.
c.
Age 3 to Attainment of Age 18—Limitation in at least two of the following areas:
(1)
Marked impairment in age-appropriate Cognitive/Communicative Function (considering historical and other information from
parents or other individuals who have knowledge of the child, when such information is needed and available); or
(2)
Marked impairment in age-appropriate Social Functioning (considering information from parents or other individuals who have
knowledge of the child, when such information is needed and available); or
(3)
Marked impairment in Personal/Behavioral Function as evidenced by marked restriction of age-appropriate activities of daily living
(considering information from parents or other individuals who have knowledge of the child, when such information is needed and
available); or persistent serious maladaptive behaviors destructive to self, others, animals, or property, requiring protective
intervention; or
(4)
Deficiencies of Concentration, Persistence, or Pace resulting in frequent failure to complete tasks in a timely manner.
DHCS 7035 C (04/08)
Page 3 of 4
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