Click here for a PDF of the checklist.  


Since My Last Visit...

Use this section to keep track of any changes since your last doctor’s visit.

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Did I experience any of the following?

  • Fatigue
  • Changes in bowel or bladder activity
  • Bruising or bleeding
  • Rashes or hives
  • Nausea or dizziness
  • Changes in appetite
  • Vomitin
  • Diarrhea
  • Changes in sex drive
  • Other side effects

Did I engage in any sexual behavior since my last visit that might have put me at risk of contracting any other sexually transmitted infections or hepatitis C?

Were there any major changes to my diet?

Did I start taking any new vitamins or supplements7 Did I travel to another country, or do I plan to?

Did I miss any doses of my HIV medication?

Were there any other changes in my life or lifestyle?

(If you answered yes to any of the above questions, be sure to discuss the topics with your doctor.)

Questions for Your Doc

Before your next appointment, use this section to jot down any questions you may have for your doctor.

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Here are some sample questions:

Are there are any lifestyle changes I should make in order to stay healthy?

What side effects can I expect from this medication?

What can I do to deal with these side effects?

How can I protect others from getting infected?

What do my lab tests mean?

Is there any additional lab work that I need to have done?

Are there any advances in treatment I should know about?

Keeping Track

Use this section to keep track of important numbers and key indicators of your risk for serious illness.

My CD4 cell count is _____

Since my last visit, it has:
O Increased O Decreased O Stayed about the same

My viral load is _____
Since my last visit. it has:
O Increased O Decreased O Stayed about the same

My blood pressure is _____
Since my last visit, it has:
O Increased O Decreased O Stayed about the same

My cholesterol (HDL/LDL) is _____
Since my last visit, it has:
O Increased O Decreased O Stayed about the same

My blood sugar (glucose) level is _____
Since my last visit, it has:
O Increased O Decreased O Stayed about the same