Review Material Patient Baseline Screen

Protect Your Health
Please take a few minutes to answer the following questions so we can
get to know you better and provide you with the best care possible.
Your answers will be kept confidential, so please answer as accurately
and honestly as you can.

Patient Name/ID:
Today’s Date:
Medical Provider:
To be filled out by provider/office staff.

Introduction
What is your preferred name?
What is your gender?

What is your relationship status?

❑ Single
❑ Married
❑ Civil union

❑ Separated
❑ Divorced
❑ Widowed

❑ One main partner
❑ Multiple partners

Who do you live with (check all that apply)?

❑
❑
❑
❑

Partner/spouse
Parent(s)
Brother(s)/sister(s)
Other relative(s)

❑
❑
❑
❑

Friend(s)
Roommate(s)
Adult children
Children under 18

❑ Alone
❑ Homeless

HIV Diagnosis and Treatment
When did you find out that you are HIV positive?
Have you ever seen a medical provider about your HIV?
Have you ever taken medicines to help control your HIV?
If yes, are you taking any medicines to help control your HIV now?

Month
❑ Yes
❑ Yes
❑ Yes

Year
❑ No
❑ No
❑ No

Sharing Your HIV Status
Since finding out that you are HIV positive, who have you told about your diagnosis in your family?

❑ Everyone in my family knows about my diagnosis.
❑ No one in my family knows about my diagnosis.
❑ Only the following person or persons in my family know about my diagnosis.

Since finding out that you are HIV positive, how many of your friends have you told about your diagnosis?

❑
❑
❑
❑

I have told most of my friends about my diagnosis.
I have told a few friends about my diagnosis.
I have told one friend about my diagnosis.
I have not told any of my friends about my diagnosis.

Since finding out that you are HIV positive, have you told any of the following people about your diagnosis
(check all that apply)?

❑ My partner/spouse
❑ My significant other, boyfriend, or girlfriend
❑ My sex partner(s)

6_PIC_W3_Baseline_Screener_v13 12-4-13

NEW PATIENT QUESTIONNAIRE

Substance Use
How often do you have a drink containing alcohol?

❑ Never
❑ Monthly or less

❑ 1-4 times a month
❑ 1-3 times a week

❑ 4 or more times a week
❑ Every day

How many drinks containing alcohol do you have on a typical day/night when you are drinking? # of drinks

In your lifetime, have you ever taken, smoked, or injected any drugs not prescribed to you by a medical provider?

❑ Yes

❑ No (skip to Sexual Activity section)

In the past 3 months, did you use crystal meth?

❑ Yes
❑ Yes

In the past 3 months, did you smoke any crack?

❑ No
❑ No

In the past 3 months, did you inject any drugs or medicines not prescribed by a medical provider?

Have you ever been in treatment for substance abuse?

❑ Yes

❑ Yes

❑ No

❑ No

Sexual Activity
❑ Yes

Over the past 3 months, did you have sex (oral, anal, or vaginal) with anyone?

How many different sex partners did you have in the past 3 months?

❑ No

# males

Have you had any main sex partners (that is, someone you would call your boyfriend/
girlfriend, spouse, significant other, or life partner) in the past 3 months?

If you currently have a main sex partner, has your partner been tested for HIV?
If yes, is your partner: ❑ HIV negative ❑ HIV positive ❑ Unsure

❑ Yes
❑ Yes

# females

❑ No
❑ No

❑ Unsure

Family Planning
Do you have children?

❑ Yes

❑ No

Are you interested in having children in the future?

❑ Yes

❑ No

Are you currently pregnant?

❑ Yes

❑ No

For women: Are you currently doing anything to prevent pregnancy such as using birth control pills?

❑ Yes

❑ No

Other
Would you like help notifying anyone that they should get tested for HIV?
This notification would be completely confidential (your name will not be used).

❑ Yes

❑ No

Are there any specific topics or questions you’d like to discuss with your medical provider today such as HIV medicines,
sexual health, substance use, depression, and/or anxiety?

Notes (for providers)

www/cdc/gov/actagainstaids/pic/