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A. General:
Fevers, chills or sweatRecent loss of appetiteFatigueRecent unexpected weight loss
B. Eyes:
Blurred or double visionEye pain or irritationEye dischargeEye painFailing visionSensitivity to light
C. Ears, Nose, Throat
EaracheRinging in earsDecreased hearingDifficulty swallowingFrequent nose bleedsFrequent sore throatProlonged hoarsenessSinus trouble or congestion
D. Cardiovascular:
Chest painFainting spellsPalpitation (fast, irregular heart)Shortness of breath with exertionSwollen ankles
E. Respiratory:
Chronic coughChronic shortness of breathChronic wheezingCoughing up bloodExcessive phlegm
F. Gastrointestinal:
Persistent nausea/vomitingDiarrheaConstipationChange in appearance of stoolChronic abdominal painBloody or very black stoolJaundice (yellow skin)
G. Skin:
Skin rashesItchingChronic dry skinSuspicious moles or other skin abnormalitiesyou are concerned about
H. Neurologic:
HeadacheUnable to move parts of your body at timesWeaknessNumbness/tingling sensationsSeizures/convulsionsFainting spellsTremor/hands shakingDizziness/vertigo
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I. If you are a woman:
Unusual vaginal dischargeLoss of control of your urinePainful urinationBlood in urineIncreased frequency of urinationHave your periods stopped?Do you have excessive flow, pain, or othermenstrual symptoms that disrupt your life?Genital soresNipple dischargeBreast mass or tendernessDesires discussion on HIVDesires Hormone Replacement TherapyDesires Birth Control
J. If you are a man:
Painful urinationBlood in urineIncreased frequency of urinationUrinating more than twice a nightLoss of control of your urineDifficulty getting or maintaining an erectionDecreased desire for sexual intercourseDesires discussion on HIV
K. Musculoskeletal:
Back painJoint painSwelling in jointsMuscle crampingMuscle weaknessMuscle stiffnessArthritis
L. Psychological:
Feeling depressed, sadMemory lossDifficulty concentratingPhobias/unexplained fearsNo pleasure in life anymore
M. Endocrine:
Cold or heat intoleranceExcessive appetiteExcessive thirst and urinationSignificant weight change
N. Heme/Lymphatic:
Excessive bruising or bleedingSwollen glands in neck, armpits, or groin
O. Allergic/Immunologic:
HivesHay feverGetting lots of infections
P. Anything else you want your doctor to be aware of?
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