ARE YOUR SIDE EFFECTS AFFECTING YOU?
Models
PART I
Help Your Doctor Help You: Rate Your Side Effects
Before each check-up, use this questionnaire to rate your side effects. Print it out or keep a log of your responses in a notebook‚ and then take it with you to every doctor visit to share and discuss. It’s a convenient tool that will make it very clear to your doctor how you’ve really been feeling between visits. Then‚ together you can determine if a change in treatment is necessary and find the one that may work best for you.

  • YES

  • NO

1) When you take your HIV medications‚ have you ever experienced
    any side effects or have trouble tolerating your medications?
If not‚ that’s great. You do not need to go any further.
Remember to come back if you begin to experience side effects.
  • Not
    at all

  • Slighty

  • Somewhat

  • Very
    much

  • Extremely

2) Think about the side effects you experience from your HIV medications.
    How frustrated or unhappy are you with those side effects?
3) How do the side effects from your HIV medications impact your physical     health and ability to function?
4) How do the side effects from your HIV medications impact your mental     function‚ for example‚ your ability to think clearly and stay awake?
5) How do the side effects from your HIV medications impact the way you feel‚     your mood‚ or your emotions?
6) How do the side effects impact how satisfied you are with your HIV     medications?