Infectious Disease Risk Assessment

In the past 30 days have you had any of these symptoms lasting more than 2 weeks?

Nausea*

Yes
No

Fever*

Yes
No

Drenching night sweats that were so bad you had to change clothes or bed sheets*

Yes
No

Productive cough*

Yes
No

Coughing up blood*

Yes
No

Shortness of breath*

Yes
No

Lumps or swollen glands in the neck or armpits*

Yes
No

Loss of weight without trying to*

Yes
No

Diarrhea lasting more than a week*

Yes
No

Brown tinged urine*

Yes
No

Women: Missed periods for last two months*

Yes
No

Extreme fatigue*

Yes
No

Jaundice or yellow eyes*

Yes
No

HIV / AIDS / Hepatitis C Risk

Did you receive a blood transfusion before 1992*

Yes
No

Have you received blood products produced before 1987 for clotting problems*

Yes
No

Was your birth mother infected by Hepatitis C during the time of your birth*

Yes
No

Have you been or are you currently on long-term kidney dialysis*

Yes
No

Have you had unprotected sex with someone who has the blood disease hemophilia*

Yes
No

Have you had unprotected sex with a person who injects drugs*

Yes
No

Have you had unprotected sex with a man who has sex with other men*

Yes
No

Have you had sex in exchange for money or drugs in order to survive*

Yes
No

Have you had unprotected sex with more than one partner in the past 6 months*

Yes
No

Have you had sex or shared needles with a person who has AIDS, HIV+, or Hep C +*

Yes
No

Have you ever injected drugs, even once*

Yes
No

Have you ever been pricked by a needle that may have been infected with HIV or Hep C*

Yes
No

Have you ever had a blood test for HIV*

Yes
No
If No would you like to be tested

If no, would you like to be tested*

Yes
No

If yes, was it within the last six months*

Yes
No

Have you ever had a blood test for Hepatitis C*

Yes
No

If no, would you like to be tested*

Yes
No

If yes, was it within the last six months*

Yes
No

How would you judge your own risk for being infected with HIV (Please check one)*

How would you judge your own risk for being infected with Hepatitis C (Please check one)*

Did the client complete the risk assessment?*

Yes
No

Was the client referred to the health department or a primary care physician?*

Yes
No

Client Signature

Date

Counselor Signature

Date

Email

This field is for validation purposes and should be left unchanged.