COMMUNICABLE DISEASE RISK SCREEN
People who report a history of substance abuse are at a greater risk for developing
certain serious communicable diseases. Please answer the following questions to
determine if you may need further health assessment.
Section 1: The following questions relate to HIV (the virus that causes AIDS),
Hepatitis A, B and/or C and Sexually Transmitted Infections (STIs), e.g., Herpes,
Gonorrhea, Syphilis, Chlamydia:
Section 2: Individuals who abuse substances are also at risk for contracting
tuberculosis (TB). Please answer the following questions to determine if you may need
health screening for TB.
- Have you ever had unprotected sex (no condom) or engaged in sexual behaviors
(oral, anal or genital) with a person whose HIV/AIDS, Hepatitis or Sexually
Transmitted Infection (STI) status is unknown to you? (For example, sex while drunk
or high with a person you do not know very well or sex with prostitutes.)
- Have you ever engaged in sexual behavior with anyone who has:
- Have you ever shared needles or injecting "works" with other individuals including
your spouse or significant other, even if just once or a long time ago?
- Have you experienced other forms of blood-to-blood or body fluid contact
(for example, blood transfusions, hemophilia treatments, employment in medical field),
and have concerns about your risk for HIV, Hepatitis or STIs?
- Have you recently lived in a substance abuse treatment facility, homeless shelter,
drug house, jail, mental hospital or in other close quarters with people you did not
- Have you recently had close contact or live with someone diagnosed with or being
treated for TB?
- Were you born in a area with a high rate of TB (e.g., Asia, Latin America, Africa,
India) or recently visited an area with a high rate of TB?
- Have you had a nagging cough for more than three weeks along with any of the
Section 3: To be completed by AAR or Treatment Program
Is this individual a high risk candidate for (mark all that apply):
If at risk, assist client by identifying applicable health referral resources on Page 3
and GIVE Page 3 to the client.
|AAR or Treatment Staff Signature