Infectious Disease Risk Assessment
Date:
-
Month
-
Day
Year
Name:
First Name
Middle Initial
Last Name
Date of Birth:
-
Month
-
Day
Year
1. Have you seen a doctor or other health care provider in the past 3 months?
*
Yes
No
Don't Know
2. Do you live or have you lived on the street or in a shelter?
*
Yes
No
Don't Know
3. Have you ever been in jail/prison, juvenile detention?
*
Yes
No
Don't Know
4. Where were you born?
5. In the past 3 years have you traveled/lived outside the U.S. (except Canada, Australia, New Zealand, Japan, Western Europe or Great Britain)?
*
Yes
No
Don't Know
6. In the past 12 months have you had a tattoo, ear/body piercing, acupuncture or come into contact with someone else’s blood?
*
Yes
No
Don't Know
7. Within the last 30 days, have you had any of the following symptoms lasting for more than 2 weeks?
Fever
Drenching night sweats that were so bad you had to change your clothes or the sheets on the bed.
Productive cough
Coughing up blood
Shortness of breath
Lumps or swollen glands in the neck or armpits
Losing weight without meaning to
Diarrhea lasting more than a week
Women: Have you missed your last two periods?
8. Have you ever been told you have TB? Has anybody you know or have lived with been diagnosed with TB in the past year?
*
Yes
No
Don't Know
9. Have you ever had a positive skin test for TB? (A test where they gave you a shot in your forearm, and a few days later a heard bump appeared.)
*
Yes
No
Don't Know
10. Have you ever been treated for TB?
*
Yes
No
Don't Know
11. Have you been told you have:
Hepatitis A
*
Yes
No
Don't Know
Hepatitis B
*
Yes
No
Don't Know
Hepatitis C
*
Yes
No
Don't Know
12. Have you ever had a job that put you in danger of needle stick injuries or other types of blood contact?
*
Yes
No
Don't Know
13. Do you use needles to shoot drugs?
*
Yes
No
Don't Know
14. Have you shared needles or syringes to inject drugs?
*
Yes
No
Don't Know
15. Do you use stimulants? (cocaine/methamphetamine)
*
Yes
No
Don't Know
16. In the last 6 months, have you or anyone you have had sex with had any sexually-transmitted diseases (STD’s), like syphilis, gonorrhea, herpes, Chlamydia, nongonococcal urethritis or hepatitis?
*
Yes
No
Don't Know
Everyone is worried about AIDS. Some should be worried and need to make some changes to avoid getting infected or spreading infection to others. However, many people are not at risks of AIDS. To help find out if you are at increased risk for HIV, the virus known to cause AIDS, please take a minute to answer the following.
17. Did you receive a blood transfusion before 1992?
*
Yes
No
Don't Know
18. Have you had unprotected sex with someone who had the blood disease hemophilia?
*
Yes
No
Don't Know
19. Have you had unprotected sex with someone who injects drugs?
*
Yes
No
Don't Know
20. Have you had unprotected sex with a man who has sex with other men?
*
Yes
No
Don't Know
21. Have you had sex in exchange for money or drugs, or in order to survive?
*
Yes
No
Don't Know
22. Have you had sex with more than one person in the past 6 months? Any type of vaginal, rectal or oral contract without protection (condom or other barrier) with or without your consent?
*
Yes
No
Don't Know
23. Have you had sex or shared needles to inject drugs with a person who has AIDS or who tested positive on the antibody test for AIDS/HIV disease?
*
Yes
No
Don't Know
24. Have you ever had a blood test for HIV antibody?
*
Yes
No
Don't Know
If NO, would you like a blood test?
Yes
No
If YES, have you been tested within the last 6 months?
Yes
No
25. Have you ever had a blood test for Hepatitis C Virus?
*
Yes
No
Don't Know
If NO, would you like a blood test?
Yes
No
If YES, have you been tested within the last 6 months?
Yes
No
26. How would you judge your own risk for being infected with HIV (the AIDS virus)?
*
I know that I am infected
I think I am at high risk
I think I am at low risk
I think I am at no risk
I am not sure what my risk is
27. How would you judge your own risk for being infected with Hepatitis C?
*
I know that I am infected
I think I am at high risk
I think I am at low risk
I think I am at no risk
I am not sure what my risk is
28. Have you ever had a drinking problem that required medical care or counseling?
*
Yes
No
Don't Know
29. Have you ever been told or thought that you had a drinking problem?
*
Yes
No
Don't Know
● If you answered “No” to all the questions, you are not at increased risk for AIDS or Hepatitis.
● If you answered “Yes” or“ Don’t Know” to any question you may be at risk for AIDS or Hepatitis.
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