Understanding instructions for medications Not taking proper # of medications Taking medications prescribed for others Not taking medications on time Other: Yes No Do you experience side effects with HIV medications? If yes, complete chart below to identify the severity. SIDE EFFECTS SEVERE SOMEWHAT A LITTLE NOT AT ALL NOT SURE Diarrhea Nausea Vomiting Constipation Headache Skin Rash Bad Dreams or confusion Fever Taste alteration Discoloration of skin or nails Numbness /tingling Drowsiness Loss of sex drive Other: Other: What have you done the side effects? What will make it easier for you to take your medications? Comments: Food and Nutrition New Need Continuing Need Since last (re)assessment, there has been: This is a: No changes Changes Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below. Current Weight Current Height Describe your appetite. (Include # of meals per day; type of food) Yes No Are you experiencing any physical problems that make it difficult to eat? Mouth problems Food allergies Nausea Diarrhea Swallowing problems Vomiting Taste Alteration Do you have any dietary restrictions? If yes, what are they? Yes No Have you gained or lost a significant Describe the reasons for the significant weight gain/loss. amount of weight in the last 6 months? Yes No Are you being treated for a weight If yes, what is the treatment? gain or loss problem? Yes No Are you receiving medical nutrition Name of Dietitian therapy? Yes No
Understanding instructions for medications Not taking proper # of medications Taking medications prescribed for others Not taking medications on time Other: Do you experience side effects with HIV medications? Yes No If yes, complete chart below to identify the severity. SIDE EFFECTS SEVERE SOMEWHAT A LITTLE NOT AT ALL NOT SURE Diarrhea Nausea Vomiting Constipation Headache Skin Rash Bad Dreams or confusion Fever Taste alteration Discoloration of skin or nails Numbness /tingling Drowsiness Loss of sex drive Other: Other: What have you done the side effects? What will make it easier for you to take your medications? Comments: Food and Nutrition Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below. Current Weight Current Height Describe your appetite. (Include # of meals per day; type of food) Are you experiencing any physical problems that make it difficult to eat? Yes No Mouth problems Food allergies Nausea Diarrhea Swallowing problems Vomiting Taste Alteration Do you have any dietary restrictions? Yes No If yes, what are they? Have you gained or lost a significant amount of weight in the last 6 months? Yes No Describe the reasons for the significant weight gain/loss. Are you being treated for a weight gain or loss problem? Yes No If yes, what is the treatment? Are you receiving medical nutrition therapy? Yes No Name of Dietitian