Health Assessment Tool
HIV/AIDS symptoms can dramatically affect your stamina, mental alertness, and overall ability to work or study. Paying close attention to how symptoms affect you can help you develop a work or school schedule that is manageable and promotes continued health.
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Health
If you are HIV+ and symptomatic, check all symptoms that you have:____Fatigue
____Poor Stamina
____Poor Concentration
____Other:
Do these conditions create limitations for you? If yes, describe those limitations.
Are you experiencing side effects from the medications? If yes, describe what they are:
What concerns do you have about maintaining your drug regimen and/or dealing with side effects while working or going to school?
How would you describe your general energy level?
____High
____Normal
____Low
____Fatigued
What are your concerns about maintaining your energy while going to work or school ?
Are you physically stable and able to engage in new activities?
____Yes
____No
Do you have difficulty performing some physical activities? If so, check all that apply.
____Walking
____Stooping/bending
____Standing
____Sitting
____Lifting
____Climbing Stairs
Other:
Do you think physical limitations will be an obstacle to your going to work or school? If yes, describe.
Describe what you could do to maintain your health, drug regimen, energy level, and physical abilities and/or deal with side effects while at work or school:
Mental Health
Has HIV affected your cognitive abilities? Check all that apply.____Memory
____Ability to concentrate
____Decision making
____Attention span
____Communication skills
Other:
How do you cope with those effects? Check all that apply.
____Make lists
____Keep a schedule or routine
____Take short breaks
____Re-check my work
____Take extra time to complete tasks
Other:
Do you currently have symptoms of depression? If yes, check all that apply.
____Increased or decreased sleep
____Changes in appetite
____Feelings of hopelessness
____Lack of pleasure
____Weight gain or loss, not HIV related
Other:
Do you currently have symptoms of anxiety? If yes, check all that apply:
____Increased worry
____Poor appetite
____Difficulty concentrating
____Irritability
____Inappropriate feelings of guilt
____Fatigue
Other:
How do you deal with anxiety and/or depression? Check all that apply.
____Rest
____Deal with my frustration
____Let go of my anger
____Address my fears
____Have a sense of the future
____Shut down/withdraw
____Seek outside help, i.e., therapy, support groups, etc.
Other:
Describe what you can do and what resources you might need to address the above symptoms.
