Ryan White | Early Intervention Services Risk Assessment

Last Name

MI

First Name

Date

HIV Status

HIV positive, not AIDS HIV positive, AIDS status unknown Undetectable

Date of onset?

HIV Risk Factor

Male to Male sexual contact (MSM)

Injecting drug use

Hemophilia/coagulation disorder

Heterosexual contact

Receipt of blood transfusion/blood components

Perinatal transmission

Sexual History

Sexual Orientation

Heterosexual

Homosexual

Bi-Sexual

Transgender

Other

Have you had more than one sexual partner in the past four months?

Yes No

Have any of your sexual partners used IV drugs since 1979?

Yes No

Have any of your partners had HIV/AIDS, been a hemophiliac, or had a positive HIV blood test?

Yes No

For Women Only

Have any of your male sex partners had sex with other men?

Yes No

Have you had Vaginal Sex?

Yes No

Have you had Anal Sex?

Yes No

Have you had Oral Sex?

Yes No

Have you had Oral Anal Sex?

Yes No

Have you ever been sexually or physically abused?

Yes No

Tobacco, Alcohol and Drug Use History

Do you smoke tobacco?

I have never smoked I currently smoke I quit

If quit, when?

If you currently smoke, do you have any interest in quitting now?

Yes No Not Sure

If yes, would you prefer to quit on your own, or with support?

Do you drink alcoholic beverages now?

Yes No

If yes, how many alcoholic beverages do you have in a week?

Bottles/cans of beer

Glasses of wine

Wine coolers

Mixed drinks or shots of liquor

Have you ever injected drugs?

Yes No

If yes have you ever shared works with anyone?

Yes No

Did you clean your works with bleach the last time you injected drugs?

Yes No

How often do you share works?

Everytime More than 50% Less than 50% Never

How often do you clean your works?

Everytime More than 50% Less than 50% Never

Are you using any other drugs or chemical substances now?

Yes No

If yes, what?

Prescribed Antiretroviral Therapy (ART)

Are you currently on HIV medication (antiretroviral therapy - ART)?

Yes No Not Sure

If yes, what is the name of your medication?

Start Date

Electronic Patient Signature