Section C: Clinical Stage
TIME THIS SECTION BEGINS RECORDED HERE
TSST03C
I’m going to ask you now about some conditions that HIV-infected patients sometimes get. Please tell me
if your health care providers such as doctors, dentists, or nurses have ever diagnosed you with any HIVor AIDS-related conditions.
C1.
Have you ever been told that you had any of the following conditions:
(Circle One on Each Line)
YES
NO
NOT
SURE
a. Candida, yeast, or thrush of the esophagus? ..........................
1
2
3
VERSIONS 11 -13:
B03C01A a. Candida or yeast infection of the esophagus or
swallowing tube? Don't count infections that
were just in your mouth ..........................................................
1
2
3
b. Herpes simplex: chronic ulcer(s) on the skin, mouth,
vagina, or esophagitis lasting more than one month? ...........
1
2
3
1
2
3
VERSIONS 6 - 10:
B03C01A
B03C01B
B03C01C
c.
Zoster, “shingles,” or reactivation
of chicken pox virus? .............................................................
NO
CERVIX
ASK d - e ONLY IF R IS FEMALE:
B03C01D
d. Cervical dysplasia, or abnormal Pap smear? ..........................
1
2
3
4
B03C01E
e. Cancer of the cervix or uterus (womb)? ...................................
1
2
3
4
B03C01F
f. Lymphoma? .............................................................................
1
2
3
IF YES TO LYMPHOMA:
C2.
Was that lymphoma of the brain?
(Circle One)
B03C02
YES ............................................... 1
NO ................................................ 2
DON'T RECALL ............................ 3
22
C3.
Have you had any HIV or AIDS-related serious or unusual infections such as:
(Circle One on Each Line)
NO
NOT
SURE
a. “Crypto,” cryptosporidiosis, or chronic bowel infection
lasting longer than one month?.................................................... 1
2
3
b. “CMV” retinitis, cytomegalovirus or other CMV
disease such as colitis or esophagitis?....................................... 1
2
3
B03C03C
c.
“Histo” or histoplasmosis?............................................................. 1
2
3
B03C03D
d. Isosporiasis (intestinal infection with isospora)?........................... 1
2
3
B03C03E
e. MAC, MAI, or Mycobacterium avium complex?............................ 1
2
3
B03C03F
f.
TB or Mycobacterium tuberculosis ?............................................. 1
2
3
B03C03G
g. PCP, Pneumocystis carinii pneumonia, or
“AIDS pneumonia”?....................................................................... 1
2
3
B03C03H
h. Two or more episodes of bacterial pneumonia?........................... 1
2
3
B03C03I
i.
Two or more episodes of salmonella in the blood
(Salmonella septicemia)?.............................................................. 1
2
3
Other serious fungal infections such as “cocci”
(coccidioidomycosis) or “blasto” (blastomycosis)?
INTERVIEWER: COCCI IS PRONOUNCED COXI ..................... 1
2
3
“Crypto,” meningitis, or cryptococcosis? ...................................... 1
2
3
YES
B03C03A
B03C03B
B03C03J
B03C03K
C4.
j.
k.
Have you ever been told you had any HIV or AIDS-related problems with your brain or nervous
system such as:
(Circle One on Each Line)
NO
NOT
SURE
a. Neuropathy (persistent pain or stinging
in hands or feet)? ........................................................................ 1
2
3
b. HIV-related encephalopathy (difficulty thinking,
remembering, concentrating)? .................................................... 1
2
3
B03C04C
c.
PML or progressive multifocal leukoencephalopathy? ................. 1
2
3
B03C04D
d. “Toxo,” “toxo encephalitis,” or
toxoplasmosis of the brain? ........................................................ 1
2
3
YES
B03C04A
B03C04B
23
C5.
Have you ever had a diagnosis of AIDS?
(Circle One)
YES ............................................... 1
B03C05
NO ................................................ 2 → SKIP TO NEXT SECTION
C6.
In what month and year were you first diagnosed with AIDS?
B03C06M
B03C06Y
MONTH:
YEAR:
24