Appendix 4: Patient Behavior Screener (English)

Form Approved

OMB No. 0920-New

Expiration Date XX/XX/XXXX

Assessment of a Comprehensive HIV Clinic-Based Intervention to Improve Patients’ Health and Reduce Transmission Risk

Appendix 4: Patient Behavioral Screener (English)

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Name: (or label) Date:

In order to provide you with the best possible health care, please take a few minutes to answer the following questions. Some questions are personal, but your answers will help us care for you. Your answers will only be seen by your health care provider.

1. Are you currently taking any medicines to treat your HIV infection? These are also called antiretroviral medicines.

☐ Yes (if Yes, go to the Question 2)

☐ No

If “NO,” Would you like to talk with your doctor about starting HIV medicines?

☐ Yes (Go to Question 3)

☐ No (Go to Question 3)

2. During the past 30 days how much of your HIV medicines did you take?

☐ NONE of my HIV medicines

☐ VERY FEW of my HIV medicines

☐ About HALF of my HIV medicines

☐ MOST of my HIV medicines

☐ ALL my HIV medicines

3. How important is it to you to come to all of your HIV medical appointments?

☐ Very important

☐ Moderately important

☐ Somewhat important

☐ Not at all important

4. In the past 3 months, did you have sex with anyone?

☐ No (If No, go to Question 7)

☐ Yes

5. In the past 3 months, with how many different people did you have sex?

☐ 1 person

☐ 2 people

☐ 3-5 people

☐ more than 5 people

6. In the past 3 months, have you had any new sex partners?

☐ No

☐ Yes

7. In the past 3 months, have you injected any drugs for fun or to feel good?

☐ No

☐ Yes

8. In the past 3 months, have you used any other drugs for fun or to feel good?

☐ No

☐ Yes

9. In the past 3 months, how often did you have five or more drinks of alcohol in a single day?

☐ Never

☐ 1 or 2 times

☐ About every month

☐ About every week

☐ Almost every day

10. How often in the past 2 weeks did you have little interest or pleasure in doing things?

☐ Not at all

☐ Several days

☐ More than half the days

☐ Nearly every day

11. How often in the past 2 weeks did you feel down, depressed or hopeless?

☐ Not at all

☐ Several days

☐ More than half the days

☐ Nearly every day