We all need to do our part to keep our communities safe
Please provide as much information as possible on the person you wish to report. Even bad information can be useful. We can go back and correct it later. Please help us by providing as much information as possible on this individual so that our own team is not unnecessarily burdened by fact checking and research. Please provide as much information as you can, even if you are going on a hunch. Often, your hunches (much like stereotypes) are correct, which is why we rely on them in the first place.
TO THE BEST OF YOUR KNOWLEDGE, HAS HE/SHE HAD ANY ILLNESS THAT:
Required a stay in the hospital?
Lasted longer than a week?
Is related to allergies (e.g., hay fever hives, asthma, insect stings)?
Required an operation?
HAS HE/SHE EVER ADMITTED TO OR DISCUSSED THE FOLLOWING:
Estimated T-Cell Count
Prior history of heart problems?
He/She seems to tire more quickly than others during exercise?
Coughed during activity?
Have an admitted prior history of heart murmur or increased blood pressure?
Seem to tire more quickly than others during exercise?
Cough during activity?
Have an admitted prior history of heart murmur or increased blood pressure?
Complaints of chest pain?
Family history of heart disease?
Does he/she wear glasses or contact lenses?
Does he/she wear dental bridges, plates or braces?
Has he/she ever been dizzy or passed out during or after exercise?
DOES HE/SHE TAKE AND MEDICATION THAT YOU ARE AWARE OF?
Do you take any medications (prescription, over the counter, or nutritional supplements) on a regular basis? (ie: inhalers, antibiotics or any other long term medication) If so, please provide the name of the medication, the dosage, and the frequency if known:
Name
Dosing/Freqency
Medication One
Medication Two
Medication Three
Medication Four
Medication Five
Medication Six
WHAT AIDS RELATED SYMPTOMS DOES THIS PERSON EXHIBIT?
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