AIDS/ARC REPORT

PATIENT:	_________________________________________
SOCIAL SECURITY #:	_________________________________________
DATE OF BIRTH:	_________________________________________

TO THE DOCTOR:

Please complete the following report, attaching lab results for each condition. Please use the back of the form if additional space is needed.

1.	Has the patient tested positive for exposure to HIV? __________ If so, give dates of test and type of test:
	DATE	TEST
	_________________	___________________________________________
	_________________	___________________________________________
	_________________	___________________________________________

2.	If the patient has tested positive for HIV, has patient been diagnosed definitely with any of the following:
	A.	Bacterial infections, multiple or recurrent of the following types	YES	NO	DATE(S)
		1. Septicemia	_____	_____	__________
		2. Pneumonia	_____	_____	__________
		3. Meningitis	_____	_____	__________
		4. Bone or joint infection	_____	_____	__________
		5. Abscess of an internal organ or body cavity	_____	_____	__________
		6. Other pyogenic bacteria	_____	_____	__________
	B.	Coccidioidomycosis disseminated at site other than or in addition to lungs or servical or hilar lymphnodes	_____	_____	__________
	C.	HIV encephalopathy	_____	_____	__________
	D.	Histoplasmosis disseminated at site other than or in addition to lungs or servical or hilar lymphnodes	_____	_____	__________
	E.	Isosporiasis with diarrhea persisting more than 1 month.	_____	_____	__________
	F.	Kaposi's sarcoma	_____	_____	__________
	G.	Lymphoma of the brain at any age	_____	_____	__________
	H.	Other non-Hodgkin's lymphoma of B-cell or unknown immunologic phenotype and the following histologic types:
		1. Small noncleaved lymphoma	_____	_____	__________
		2. Immunoblastic sarcoma	_____	_____	__________
	I.	Any mycobacterial disease caused by mycobacteria other than M. tuberculosis disseminated at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes	_____	_____	__________
	J.	Disease caused by M. tuberculosis, extra- pulmonary (involving at least one site outside the lungs) other than or in addition to lungs, skin, or cervical or hilar lymph nodes	_____	_____	__________
	K.	Salmonella (nontyphoid) septicemia, recurrent	_____	_____	__________
	L.	HIV wasting syndrome	_____	_____	__________
3.	If the patient has tested positive for HIV, has patient been diagnosed presumptively with any of the following diseases:
	A.	Candidiasis of esophagus	_____	_____	__________
	B.	Cytomegalovirus retinitis with loss of vision	_____	_____	__________
	C.	Kaposi's sarcoma	_____	_____	__________
	D.	Lymphold interstitial pneumonia and/or pulmonary lymphold hyperplasia	_____	_____	__________
	E.	Mycobacterial disease, disseminated in at least one site other than in addition to lungs, skin, or cervical, or hilar lymph nodes	_____	_____	__________
	F.	Pneumocystis carinii pneumonia	_____	_____	__________
	G.	Toxoplasmosis of brain	_____	_____	__________
4.	If the patient is without lab evidence of HIV or with laboratory evidence against HIV infection, has patient been diagnosed definitively with any of the following:
	A.	Candidiasis of the esophagus, trachea, bronchi or lungs	_____	_____	__________
	B.	Cryptococcosis, extra-pulmonary	_____	_____	__________
	C.	Cryptococcosis with diarrhea persisting more than 1 month	_____	_____	__________
	D.	Cytomegalovirus disease of an organ other than liver, spleen or lymph nodes	_____	_____	__________
	E.	Herpes simplex virus causing a mucocutaneous ulcer that persists more than 1 month, or bronchitis, pneumonitis or esophagitis	_____	_____	__________
	F.	Kaposi's sarcoma	_____	_____	__________
	G.	Lymphoma of the brain (primary)	_____	_____	__________
	H.	Lymphoid interstitial pneumonia and/or pulmonary lymphoid hyper-plasia	_____	_____	__________
	I.	Mycobacterium avium complex or M. Kansasii disease, disseminated	_____	_____	__________
	J.	Pneumocystis carinii pneaumonia	_____	_____	__________
	K.	Progressive multifocal leukoencephalopathy	_____	_____	__________
	L.	Toxoplasmosis of the brain	_____	_____	__________
5.	If the patient is without lab evidence of HIV infections, has patient:
	A.	Received high dose or long-term systemic corticosteroid therapy or other immuno-suppressive/cytoxic therapy less than or equal to 3 months before the onset of the indicator disease?
		Yes ________ No __________. If yes, describe: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________
	B.	Been diagnosed with any of the following diseases with 3 months after diagnosis of any indicator disease listed in question 4 above:
			YES	NO
		1. Hodgkin's disease	_____	_____
		2. Non-Hodgkin's lymphoma (other than primary brain lymphoma)	_____	_____
		3. Multiple myeloma	_____	_____
		4. Any other cancer of lymphomticular or histocyctic tissue	_____	_____
		5. Angioimmunoblostic lymphadenopathy	_____	_____
6.	If the patient has laboratory test results negative for HIV, does patient have a T-help/inducer (CD4) lumphocyte count under 400/mm?
		Yes ________ No __________. If yes, describe: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

___________________________________ Signature	_________________________ Date
__________________________________ NAME (PLEASE PRINT)
__________________________________ SPECIALTY
__________________________________ ADDRESS
__________________________________ PHONE

Law Office Of:
Jerrold S. Zivic
850 W. Jackson Blvd.
Suite 405
Chicago, IL 60607
800-400-4357