VISIT CLINICIAN NUMBER NUMBER FOLLOW–UP VISIT 4 5 0 PHYSICAL EXAM 0 0 0 0 0 1 1 1 1 1 MARKING INSTRUCTIONS 2 2 2 2 2 • Make dark marks that fill 3 3 3 3 3 the circle completely. 4 4 4 4 4 4 • Make clean erasures. Correct Mark: 5 5 5 5 5 • Make NO stray marks. Incorrect Marks: ✗✓ 6 6 6 6 6 • Do NOT fold this form. 7 7 7 7 7 8 8 8 8 8

M A C S 9 9 9 9 9 4.a NO YES Did participant refrain from caffeine 4.b 1. 2. 3. and nicotine for at least 30 minutes prior to first BP reading? PRESSURE ID NUMBER DATE WEIGHT Did participant sit quietly for about 5 minutes prior to first BP reading? JAN DAY YR KILOGRAMS Right PERF FEB Did participant sit quietly for about Left • 5 minutes prior to second BP reading? 0 0 0 0 MAR 0 0 00 0 0 0 0 1 1 1 1 1 APR 10 1 01 1 1 1 1 FIRST READING SECOND READING 5. 2 2 2 2 2 MAY 20 2 02 2 2 2 2 BLOOD PRESSURE ORAL TEMPERATURE At least 30 minutes after 3 3 3 3 3 JUNE 30 3 03 3 3 3 3 Sitting, Right Arm Sitting, Right Arm smoking, eating, or drinking 4 4 4 4 4 JULY 4 04 4 4 4 4 SYSTOLIC DIASTOLIC SYSTOLIC DIASTOLIC °F 5 5 5 5 AUG 5 05 5 5 5 5 • 6 6 6 6 SEPT 6 06 6 6 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 7 7 7 OCT 7 07 7 7 7 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 8 8 8 8 NOV 8 08 8 8 8 2 2 2 2 2 2 2 2 2 2 2 2 2 9 9 9 9 DEC 9 09 9 9 9 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 5/8" SLIT Glue 8 8 8 8 8 8 8 8 8 8 8 9 9 9 9 9 9 9 9 9 9 9

6. /HAIR/NAILS (Excluding genital area) i. Kaposi’s NO YES REFUSED a. Fungal infection lesions (excluding athletes foot) 1) Skin Lesions NO YES REFUSED IF YES: Number of lesions 1) Intertriginous candida 1–2 3–10 >10 2) Tinea versicolor Diameter of largest lesion in cms. 3) Onychomycosis 0 102030405060708090 cms 012345 6789 b. Herpes Zoster (active) c. Molluscum contagiosum 2) Oral lesions d. Seborrhea 3) Anal/perianal lesions e. Psoriasis Not examined f. Jaundice Comments: g. Spider PERF

h. Other (please describe below)

SERIAL #

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REFUSED 7. OROPHARYNGEAL NO YES 9. LYMPH NODES NO YES REFUSED a. Consistent with oral thrush/candidiasis a. Are there any nodes present IF YES: (excluding inguinal and femoral) KOH negative which are >1 cm? -OR- SKIP TO Q 10 KOH positive Not performed b. Presence of node >1 cm b. Consistent with herpetic lesions c. Gingivitis/gum disease Right 1) Occipital d. Oral hairy leukoplakia Left e. Other (please describe below)

Right PERF 2) Post. auricular Left

Right 3) Pre-auricular Left

Right 4) Submental/submandibular Left

Right 5) Ant. cervical Left

6) Post. cervical Right Left

Right 7) Supraclavicular

Left Glued 8) Axillary Right 5/8" Left 8. EYES NO YES REFUSED a. Conjuctiva Right 9) Epitrochlear 1) Redness Left 2) Discharge b. Scleral icterus c. Other (please describe below) c. What is the diameter of the largest node present? 1–2 cm 2.1–4 cm >4 cm NO YES d. Are any of the nodes tender?

e. Are any of the nodes matted? PERF

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10. ABDOMEN Did the MACS perform an anal/rectal exam on this a. REFUSED participant within the past 6 months? Percussed size in mid-clavicular line NO YES IF YES, SKIP TO Q 12 GENITALIA EXAM 0 102030405060708090 cms 012345 6789 Mark here if entire rectal exam was declined NO YES REFUSED 1. Ascites 11. ANAL/RECTAL EXAMINATION NO YES REFUSED a. Discharge b. Herpetic lesions c. Warts b. Spleen (Rt. lateral decubitus, d. Prostate flexed knees/hips) NO YES REFUSED 1) Enlarged Palpable on inspiration below 2) Tender left costal margin e. Digital exam 1) Tender anal canal Size below LCM f. , external 0 102030405060708090 g. Laceration/Fissure/Fistula cms PERF 012345 6789 h. Other (please describe below) NO YES REFUSED c. Other (please describe below)

Mark here if genitalia exam was declined

12. GENITALIA NO YES REFUSED a. Urethral discharge b. Skin 1) Condyloma acuminata (warts) 2) Pediculosis 3) Tinea cruris/Candida 5/8" SLIT Glue 4) Herpetic lesions (active) c. Other(please describe below)

13. EXAMINER’S IMPRESSIONS (use back of page if necessary)

NOT NORMAL ABNORMAL COMMENTS PERFORMED General Appearance

Chest and Lungs

PERF Heart

Extremities

Neurological Exam

SERIAL #

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14. PERIPHERAL NEUROPATHY SCREENING RIGHT LEFT a1. Perception of vibration (at great toe) NO a2. Perception of vibration (at great toe) NO YES YES Unable to evaluate Unable to evaluate REFUSED REFUSED IF YES: Vibration >10 sec. (normal) IF YES: Vibration >10 sec. (normal) was felt for: 5–10 sec. (mild loss) was felt for: 5–10 sec. (mild loss) >0 and <5 sec. (moderate loss) >0 and <5 sec. (moderate loss) 0 sec. (severe loss) 0 sec. (severe loss)

RIGHT LEFT PERF b1. Deep tendon reflexes (ankle reflexes) NO, reflexes absent b2. Deep tendon reflexes (ankle reflexes) NO, reflexes absent YES, reflexes present YES, reflexes present Unable to evaluate Unable to evaluate REFUSED REFUSED IF YES: Reflexes Hypoactive IF YES: Reflexes Hypoactive felt were: Normal deep tendon reflexes felt were: Normal deep tendon reflexes Hyperactive deep tendon reflexes Hyperactive deep tendon reflexes (e.g., with prominent spread) (e.g., with prominent spread) Clonus Clonus

Additional Comments:

Glued

5/8" PERF

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LIPODYSTROPHY QUESTIONNAIRE

1a. Since your last visit in [MONTH], have you noticed any changes in the distribution or in the amount of your body (either loss or gain)? [Changes include first time occurrences and increases or decreases in severity since your last visit.] NO (IF “NO”, SKIP TO PAGE 6) YES REFUSED (IF “REFUSED”, SKIP TO PAGE 6)

1b. If “yes” which parts of If No or Refused, go to Was this change an your body were affected, next question. If Yes, increase or and how severely? indicate type of change decrease? Current Severity [ASK EACH ITEM AND and severity of symptom. RECORD ANSWER] Refused No Yes Increase Decrease None MildModerate Severe 1) Facial fat 2) Arm fat PERF 3) Leg fat 4) Buttocks fat 5) Belly (abdomen) fat 6) Fat on back of 7) Breasts 8) Hips 9) Other (if Yes, specify below)

1c. Since you’ve noticed these changes, have you taken actions that would influence your fat distribution such as:

[ASK EACH ITEM AND RECORD ANSWER] No Yes Refused No Yes Refused 1) Changing diet 6) Liposuction surgery 5/8" SLIT Glue 2) Changing HIV medications 7) Cheek implants/injections 3) Exercise/Weight lifting 8) Other cosmetic surgery 4) Taking nutritional supplements 9) Other (if Yes, specify below) 5) Taking growth hormone or steroids

2. Since your last visit in [MONTH], If No or Refused, go to Was this change an next question. If Yes, Amount of change since have you noticed any change in: increase or your last visit. indicate if change was an decrease? increase or decrease and the amount of change. Refused No Yes Increase Decrease <1 in. 1–2 in. >2 in. 1) Shirt neck size? 2) Trouser waist size? PERF

Mark Reflex® forms by NCS Pearson EM-228123C-15:654321 Printed in U.S.A.

SERIAL #

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LIPODYSTROPHY

LIPODYSTROPHY 1. Height: 2. Mid-Arm Girth: 3. Chest Girth: 4. Waist Girth: 5. Hip Girth: 6. Thigh Girth MEASURER CODE ¥ cm ¥ cm ¥ cm ¥ cm ¥ cm ¥ cm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 3 3 3 3 R 3 3 3 R 3 3 3 3 R 3 3 3 3 R 3 3 3 3 R 3 3 3 3 R 2 2 2 E E E E E E 4 4 4 4 F 4 4 4 F 4 4 4 4 F 4 4 4 4 F 4 4 4 4 F 4 4 4 4 F 3 3 3 5 5 5 5 U 5 5 5 U 5 5 5 5 U 5 5 5 5 U 5 5 5 5 U 5 5 5 5 U 4 4 4 S S S S S S 6 6 6 6 E 6 6 6 E 6 6 6 6 E 6 6 6 6 E 6 6 6 6 E 6 6 6 6 E 5 5 5

7 7 7 7 D 7 7 7 D 7 7 7 7 D 7 7 7 7 D 7 7 7 7 D 7 7 7 7 D 6 6 6 PERF 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 7 7 7 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 8 8 8 (see instructions) (see instructions) (see instructions) (see instructions) (see instructions) (see instructions) 9 9 9

7. Thigh Skinfold: 8. Triceps 9. Subscapular 10. Biceps 11. Breast 12. Abdominal 13. Suprailiac Skinfold: Skinfold: Skinfold: Skinfold: Skinfold: Skinfold: ¥ mm ¥ mm ¥ mm ¥ mm ¥ mm ¥ mm ¥ mm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 R 3 3 3 R 3 3 3 R 3 3 3 R 3 3 3 R 3 3 3 R 3 3 3 R E E E E E E E 4 4 4 F 4 4 4 F 4 4 4 F 4 4 4 F 4 4 4 F 4 4 4 F 4 4 4 F 5 5 5 U 5 5 5 U 5 5 5 U 5 5 5 U 5 5 5 U 5 5 5 U 5 5 5 U S S S S S S S 6 6 6 E 6 6 6 E 6 6 6 E 6 6 6 E 6 6 6 E 6 6 6 E 6 6 6 E 7 7 7 D 7 7 7 D 7 7 7 D 7 7 7 D 7 7 7 D 7 7 7 D 7 7 7 D 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

14. Fat Wasting (see severity definitions below): If None or Refused, go to next question.

Severity* Glued If Yes, indicate severity of symptom. 5/8" Refused None Yes MildModerate Severe 1) Facial fat loss (sunken cheeks) 2) 3) Legs 4) Buttocks

15. Fat Accumulation: If None or Refused, go to next question. If Yes, indicate severity of symptom. Severity* Refused None Yes MildModerate Severe 1) Moon facies 2) Abdomen

3) Back of Neck PERF 4) Breasts

16. Other physical exam findings noted related to fat distribution:

Specify:

* Definitions: None: Patient does not exhibit any signs of fat maldistribution. (Not noted by patient or clinician) Mild: Mild signs noted only after close inspection by patient or clinician. Moderate: Signs of fat maldistribution are noticed by patient or clinician without specifically looking for it. Patient may complain that current clothing has become tighter. Severe: Signs of fat maldistribution easily noted by casual observer. Symptoms have required a change in size of clothing or undergarments worn.

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