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.

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.

Yes

No

What concerns do you have about maintaining your drug regimen and/or dealing with side effects while working or going to school?

Are you experiencing side effects from the medications? If yes, describe what they are:

Are you physically stable and able to engage in new activities?

Yes

No

Other side effects:

Other Difficult Activities:

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

Communication skills

Other

Other Cognitive Abilities Affected:

How do you cope with those effects? Check all that apply.

Other Coping Mechanisms:

Do you currently have symptoms of depression? Check all that apply.

Other Symptoms of Mental Depression:

Other symptoms of mental anxiety:

How do you deal with anxiety and/or depression? Check all that apply.

Other Mechanisms for coping with Anxiety or Depressions:

Describe what you can do and what resources you might need to address the above symptoms: