SURVEY BEGINS
NAME: AndWellness Home
TRIGGERED BY: USER – OTHER TRIGGERS ARE SUB-SURVEY SPECIFIC
INTRODUCTION: Welcome to AndWellness.
Q1: Select a survey to begin:
1. Specific Stressful Event
2. General Feeling Today
3. Medication
4. Sexual Encounters
5. Alcohol, Tobacco, Drugs
6. Photo Diary
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NAME: Specific Stressful Event Survey
TRIGGERED BY: USER
Q1. What happened?
TEXT
BUTTON:SKIP, BACK, SUBMIT
Q2. What time did this happen?
TIME
BUTTON:SKIP, BACK, SUBMIT
Q3. Take a picture related to the stress or event
IMAGE
BUTTON:SKIP, BACK, SUBMIT
NOTE: BRANCH TO ANDWELLNESS HOME
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NAME: General Feeling Today Survey
TRIGGERED BY: USER, TIME (END OF DAY & USER PROGRAMMABLE)
INTRO: How are you feeling today?
Q1. Sad, blue, or depressed?
SINGLE CHOICE
0. Not at all
1. A little
2. Somewhat
3. Extremely
BUTTON:SKIP, BACK, SUBMIT
Q2. Worried, tense, or anxious?
SINGLE CHOICE
0. Not at all
1. A little
2. Somewhat
3. Extremely
BUTTON:SKIP, BACK, SUBMIT
Q3. Not get enough rest or sleep?
SINGLE CHOICE
0. Not at all
1. A little
2. Somewhat
3. Extremely
BUTTON:SKIP, BACK, SUBMIT
Q4. Very healthy and full of energy?
SINGLE CHOICE
0. Not at all
1. A little
2. Somewhat
3. Extremely
BUTTON:SKIP, BACK, SUBMIT
Q5. Usual activities were hard to do?
SINGLE CHOICE
0. Not at all
1. A little
2. Somewhat
3. Extremely
BUTTON:SKIP, BACK, SUBMIT
NOTE: BRANCH TO ANDWELLNESS HOME
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NAME: Medication Survey
TRIGGERED BY: USER, TIME (END OF DAY & USER PROGRAMMABLE)
Q1. Which medication do you want to report on?
SINGLE CHOICE CUSTOM
Q2. Did you take or miss taking this medication today?
SINGLE CHOICE
0. Missed – BRANCH Q6
1. Took
BUTTON:SKIP, BACK, SUBMIT
Q3. What time did you take this medication?
TIME
BUTTON:SKIP, BACK, SUBMIT
Q4. Was this on time?
SINGLE CHOICE
0. No
1. Yes – BRANCH Q7
BUTTON:SKIP, BACK, SUBMIT
Q5. Why were you late taking this medication?
MULTICHOICECUSTOM
1. Forgot
2. Ran out
3. Didn’t have with me
4. Didn’t want people to see
5. Other
BUTTON:SKIP, BACK, SUBMIT
BRANCH Q7
Q6. Why did you miss taking this medication?
MULTICHOICECUSTOM
1. Forgot
2. Ran out
3. Didn’t have with me
4. Didn’t want people to see
5. Other
BUTTON:SKIP, BACK, SUBMIT
Q7. Do you want to report on another medication now?
0. No – BRANCH TO SUBMIT SCREEN
1. Yes
BUTTON:SKIP, BACK, SUBMIT
Q8. After submitting this survey please launch a survey for your other medication at the home screen.
INFORMATIONAL
NOTE: BRANCH TO SUBMIT SCREEN
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NAME: Sexual Encounter Survey
TRIGGERED BY: USER, TIME (END OF DAY & USER PROGRAMMABLE)
INTRO: The following questions ask about each individual sexual activity you engaged in during one encounter. Please start with the first sexual encounter since your last report at [TIME & DAY].
Q1. How many hours ago did the encounter end?
NUMERIC
DEFAULT: 0
MIN: 0
MAX: 24
BUTTON:SKIP, BACK, SUBMIT
Q2. Enter or select this partner’s nickname (to protect privacy).
SINGLE CHOICE CUSTOM
BUTTON:SKIP, BACK, SUBMIT
Q3. What type of partner was this?
SINGLE CHOICE
1. One-time
2. Casual
3. Regular
BUTTON:SKIP, BACK, SUBMIT
Q4. Partner’s Gender?
SINGLE CHOICE
1. Male
2. Transgender
3. Female
BUTTON:SKIP, BACK, SUBMIT
Q5. What is this partner’s HIV status?
SINGLE CHOICE
1. Positive
2. Negative
3. Don’t Know
BUTTON:SKIP, BACK, SUBMIT
Q6. Did you and this partner discuss safe sex or using condoms?
SINGLE CHOICE
0. No
1. Yes (this time)
2. Yes (but not this time, only previously)
BUTTON:SKIP, BACK, SUBMIT
Q7. What kind of sexual activities did you engage in?
MULTI CHOICE
1. Anal – BRANCH Q8
2. Oral – BRANCH Q10
3. Vaginal – BRANCH Q12
BUTTON:SKIP, BACK, SUBMIT (NOTE: CONTINUE TO Q8)
Q8. What was your position during anal sex?
MULTICHOICE
1. Received (“bottom”)
2. Inserted (“top”)
BUTTON:SKIP, BACK, SUBMIT
Q9. Did you use condoms during anal sex in this encounter?
SINGLE CHOICE
0. No – BRANCH TO END OF SURVEY (note – this really means back to Q7)
1. Yes - BRANCH TO END OF SURVEY
BUTTON:SKIP, BACK, SUBMIT
Q10. What was your role during oral sex?
MULTICHOICE
1. Received – BRANCH TO END OF SURVEY
2. Performed – BRANCH TO END OF SURVEY
BUTTON:SKIP, BACK, SUBMIT
Q11. Did you use condoms during oral sex in this encounter?
SINGLE CHOICE
0. No
1. Yes
BUTTON:SKIP, BACK, SUBMIT
Q12. Did you use condoms during vaginal sex in this encounter?
SINGLE CHOICE
0. No
1. Yes
BUTTON:SKIP, BACK, SUBMIT
Q13. Were you intoxicated (high on alcohol or drugs) during this encounter?
SINGLE CHOICE
0. No
1. Yes
BUTTON:SKIP, BACK, SUBMIT
Q14. You can write notes about this encounter here.
TEXT
BUTTON:SKIP, BACK, SUBMIT
Q15. Did you have any other sexual encounters since your last survey?
SINGLE CHOICE
0. No – BRANCH TO SUBMIT SCREEN
1. Yes
BUTTON:SKIP, BACK, SUBMIT
Q16. After submitting this survey please launch a survey for another sexual encounter at the home screen.
INFORMATIONAL
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NAME: Alcohol, Tobacco, & Other Drug Survey
TRIGGERED BY: USER, TIME (END OF DAY & USER PROGRAMMABLE)
Q1. Which substances did you use since your last report at [TIME & DAY]?
MULTICHOICE
1. Alcohol
2. Tobacco – BRANCH TO Q4
3. Marijuana – BRANCH TO Q5
4. Cocaine – BRANCH TO Q7
5. Methamphetamine (“Crystal”) – BRANCH TO Q9
6. Other – BRANCH TO Q11
BUTTON:SKIP, BACK, SUBMIT (NOTE: CONTINUE TO Q2)
Q2. How many drinks have you had since your last report?
NUMERIC
DEFAULT: 1
MIN: 1
MAX: 24
BUTTON:SKIP, BACK, SUBMIT
Q3. What time was the first drink today?
TIME
BUTTON: DID NOT DRINK TODAY
BUTTON:SKIP, BACK, SUBMIT
Q4. How many cigarettes have you smoked since your last report?
NUMERIC
DEFAULT: 1
MIN: 1
MAX: 24
BUTTON:SKIP, BACK, SUBMIT
Q5. How many times did you use marijuana since your last report?
NUMERIC
DEFAULT: 1
MIN: 1
MAX: 24
BUTTON:SKIP, BACK, SUBMIT
Q6. What time did you first use marijuana today?
TIME
BUTTON: DID NOT USE TODAY
BUTTON:SKIP, BACK, SUBMIT
Q7. How many times did you use cocaine since your last report?
NUMERIC
DEFAULT: 1
MIN: 1
MAX: 24
BUTTON:SKIP, BACK, SUBMIT
Q8. What time did you first use cocaine today?
TIME
BUTTON: DID NOT USE TODAY
BUTTON:SKIP, BACK, SUBMIT
Q9. How many times did you use meth/crystal since your last report?
NUMERIC
DEFAULT: 1
MIN: 1
MAX: 24
BUTTON:SKIP, BACK, SUBMIT
Q10. What time did you first use meth/crystal today?
TIME
BUTTON: DID NOT USE TODAY
BUTTON:SKIP, BACK, SUBMIT
Q11. What other drugs did you use since your last report?
TEXT
BUTTON:SKIP, BACK, SUBMIT
Q12. You can write notes about your alcohol, tobacco, or other drug use here.
TEXT
BUTTON:SKIP, BACK, SUBMIT
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NAME: Photo Diary
TRIGGERED BY: USER
INTRODUCTION: You can use this photo diary to take pictures and record notes.
Q1. Take a photo.
IMAGE
Q2. Write a note.
TEXT
BUTTON:SKIP, BACK, SUBMIT
NOTE: BRANCH TO ANDWELLNESS HOME