Hiv/Aids/Tb/Std Risk Assessment

Confidential

HIV/AIDS/TB/STD RISK ASSESSMENT

CDS Family & Behavioral Health Services, Inc.

Participant Name: / Number:
Participant Self-Evaluation Of Risk Factors For HIV and Other Sexually Transmitted Diseases
Have you ever been tatooed or had an ear or other body parts pierced? / Yes  No
Have you ever traded sex for drugs, money, or shelter? / Yes  No
Are you a hemophiliac (free bleeder) or blood recipient? / Yes  No
Have you had a health care exposure to HIV? / Yes  No

Have you had sexual activity with someone who is:

Check all that apply about your sexual history since 1978.
Needle user / Yes  No
Homosexual/Bisexual / Yes  No
Not born in USA / Yes  No
HIV Positive / Yes  No
Multiple prison terms / Yes  No
Other HIV risks (see above) / Yes  No
Have you had more than one sexual partner since 1978? / Yes  No
Have you had more than one sexual partner this year? / Yes  No
Partner’s HIV status (Check all that apply)
 Positive Negative Unknown /

Date partner(s) tested

Do you, or your partner, use a contraceptive: (excluding condoms)? / Yes  No
Do you, or your partner, use condoms? / Yes  No
Have you had unprotected sex in the past six months? (This includes any type of vaginal, rectal, or oral contact without a condom.) / Yes  No
Have your had sex while under the influence of drugs, including alcohol? / Yes  No
When drinking or using drugs, are you more likely to have unprotected sex with someone? / Yes  No

Have you ever had a sexually transmitted disease?

/ Yes  No
If so which:
Check all that apply / Syphilis /

Gonorrhea/Clap

/

Herpes

/ Chlamydia / HPV/ Warts
For Women: Have you missed your last two periods? / Yes  No

Updated 11/04, 9/07F-PR-1038

Confidential

Participant Self-Evaluation Of Risk Factors For Tuberculosis
Have you ever been told you have tuberculosis? / Yes  No
Have you known or lived with someone diagnosed with tuberculosis in the past year? / Yes  No
Do you live on the street or in a shelter? / Yes  No
Within the past 30 days have you, or some one you live with, had any of the following symptoms: Coughing up blood, drenching night sweats (so bad you had to change clothes or sheets), or diarrhea (runs) for more than a week. / Yes  No
Have you had Hepatitis B or Hepatitis C? / Yes  No
Have you been vaccinated for the Hepatitis B virus? / Yes  No

I have been counseled concerning my answers on the questionnaire and have been provided information concerning reducing my risk of HIV exposure and infection. (Please sign after session with your counselor.)

Participant’s Signature______Date______

Counselor’s Signature ______Date ______

Participant provided referral information for HIV and other health screenings.

Participant is interested in HIV testing and or other health screenings.

Participant is not interested in HIV testing and or other health screening.

Updated 11/04, 9/07F-PR-1038