Risk Assessment Questionnaire

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:

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.)

Yes No

Have you ever engaged in sexual behavior with anyone who has:

Injected drugs	Yes	No
Traded sex for drugs	Yes	No
Many sexual partners	Yes	No
HIV/AIDS	Yes	No
Hepatitis	Yes	No
STIs	Yes	No

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?

Yes No

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?

Yes No

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 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 know well?

Yes No
Have you recently had close contact or live with someone diagnosed with or being treated for TB?

Yes No
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?

Yes No

Have you had a nagging cough for more than three weeks along with any of the following symptoms?

Weight loss	Yes	No
Fever for 3 days or longer	Yes	No
Night sweats	Yes	No
Coughing up blood	Yes	No

Client Signature Date

Section 3: To be completed by AAR or Treatment Program

Is this individual a high risk candidate for (mark all that apply):

HIV Yes

STIs Yes

Hepatitis Yes

TB Yes

If at risk, assist client by identifying applicable health referral resources on Page 3 and GIVE Page 3 to the client.

	Public Health (HIV/AIDS, TB, STI Clinic, Hepatitis)
	Private Physician	Name:
Note: Release of information for communication with primary care provider should be completed. Documentation of refusal to sign release should also be included in record
	TB, STI or Hepatitis Hotlines/Resources
	Health Care/Indigent Health Assistance/Resources
	Other Resources not Listed	Specify:

Additional Comments:

AAR or Treatment Staff Signature Date