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HIV/STD/Hepatitis Risk Assessment

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Client Name or ID Date

Introduction to Client: I am going to ask you a series of questions to assess your risk for sexually transmitted diseases, including hepatitis and HIV. These are very
personal and intimate questions. In order to give you an accurate assessment of your health risks, I need to ask these questions and it’s important that you answer as
honestly and accurately as possible.

3a. What was the result of
your most recent test?

PART ONE: INFECTION STATUS

1. To the best of you r knowled g e , do you n ow have or have you ever had any of the f ollowi ng?
Gonorrhea � Yes � No � Don’t know
Chlamydia � Yes � No � Don’t know

Syphilis � Yes � No � Don’t know
Herpes � Yes � No � Don’t know

Anal/Genital Warts or HPV � Yes � No � Don’t know
Viral Hepatitis � Yes � No � Don’t know

If no or don’t know to all, skip to Question 2

1a. If yes, are you currently being treated or were you previously treated for?
Gonorrhea � Yes � No � Don’t know
Chlamydia � Yes � No � Don’t know

Syphilis � Yes � No � Don’t know
Herpes � Yes � No � Don’t know

Anal/Genital Warts or HPV � Yes � No � Don’t know
Hepatitis B � Yes � No � Don’t know
Hepatitis C � Yes � No � Don’t know

If no or don’t know:
� Provide/refer to care for appropriate STD and/or hepatitis

2. Have you been vaccinated for?

Hepatitis A � Yes � No � Don’t know

Hepatitis B � Yes � No � Don’t know
If no or don’t know to either:
� Provide/refer to testing and vaccination

3. When di d you have your most
recent HIV test?

� Never been tested
Date of most recent test

If never been tested, skip to Question 4

� Positive � Negative � Don’t know
If negative or don’t know, skip to Question 4

3b. If positive, have you seen a
physician for HIV medical care in
the last 6 months?

� Yes � No

The purpose of this risk assessment tool is to help providers identify individuals at highest risk of acquir

If no:
� Refer to HIV medical care

ing and/or transmitting STDs, HIV and/or hepatitis in order to:
1) conduct appropriate testing, vaccination, health education and risk reduction counseling, and 2) provide referrals to staff/agencies/clinics that offer those services.

P TWO: S RISK P TWO: S RISK

oral sex with more than one
partner

oral sex with anyone
year?

� Yes � No �

If :
�

�
� Yes � No �

If :
�

�

infections

vaginal
partner

vaginal in the
last year?

� Yes � No �

If :
�

�

� Yes � No �

If :
�

�

infections

anal sex with more than one
partner

anal sex with anyone
year?

� Yes � No �

If :
�

�
� Yes � No �

If :
�

�

infections

�

bacterial STD,

Fo ,
OR

ART EXUAL ART EXUAL

4. Have you had unprotected
in the last year?

4. Have you had unprotected in the last

Don’t know

yes or don’t know
Provide/refer to risk reduction
counseling and

Provide/refer to testing for STDs,
and hepatitis A and B

Don’t know

yes or don’t know
Provide/refer to risk reduction
counseling and

Provide/refer to testing for other
possible sexually transmitted

5. Have you had unprotected sex with more than one
in the last year?

5. Have you had unprotected sex with anyone

Don’t know

yes or don’t know
Provide/refer to risk reduction
counseling and

Provide/refer to testing for HIV,
STDs, and hepatitis B

Don’t know

yes or don’t know
Provide/refer to risk reduction
counseling and

Provide/refer to testing for other
possible sexually transmitted

6. Have you had unprotected
in the last year?

6. Have you had unprotected in the last

Don’t know

yes or don’t know
Provide/refer to risk reduction
counseling and

Provide/refer to testing for HIV,
STDs, and hepatitis A and B

Don’t know

yes or don’t know
Provide/refer to risk reduction
counseling and

Provide/refer to testing for other
possible sexually transmitted

Continue with Part Three on the following page
If yes to any of the above:

Emphasize the need for partner(s) to
get tested for infection(s) that the
client has

Continue with Part Three on the following page

For clients who are NOT KNOWN TO BE INFECTED with HIV,
an STD, or hepatitis; or have completed treatment for a

follow the questions below:

r clients who ARE CURRENTLY INFECTED with HIV
hepatitis A or B, and/or an STD,

follow the questions below:

Page 2

Client Name or ID Date

P THREE: INJECTION HISTORY

medications?
� Yes � No

If no

If yes i
�

8. Have you been tested for HIV since the last time you injected? /AIDS)

� Yes � No �
If :
�

9. Have you been tested for hepatitis B since the last time you injected?

� Yes � No �

If :
�

If :
�

If

�

� Yes � No �
If :
�
�

ly infected n
If not, skip to Questio

� Yes � No
If yes:
� and
�

P FOUR: OTHER QUESTIONS

ART

7. Have you ever injected drugs or anything else,
such as hormones, steroids, or non-prescription

, skip to Question 12

, continue with Quest ons 8, 9, 10 and:
Provide/refer to risk reduction counseling

(Skip to Question 9 if client has HIV

Don’t know
no or don’t know
Provide/refer to HIV testing

(Skip to Question 10 if client has been vaccinated for hepatitis B)

Don’t know

no or don’t know
Provide/refer to hepatitis B testing and vaccination

yes and client has never had hepatitis B
Provider/refer to vaccination

yes and client still has hepatitis B and is not
receiving treatment:

Provide/refer to treatment

10. Have you been tested for hepatitis C since the last time you injected? (Skip to Question 11 if client currently has hepatitis C)

Don’t know
no or don’t know
Provide/refer to hepatitis C testing and
Provide education on possibility of re-infection

If client is current with HIV, hepatitis B, a d/or hepatitis C, continue with Question 11
n 12

11. Have you ever shared needles and/or other
injection equipment? Provide/refer to risk reduction counseling

Recommend that partner(s) get tested for infection(s) that client has

ART

12. These questions have focused on the highest risk behaviors. What
questions or concerns do you have about these or other risk
behaviors?

13. What questions or concerns do you have about another person’s
behaviors that might put you at risk?

Page 3

Testing:

Vaccinations:

Risk Reduction Counseling:

Other:

Summary of Recommendations

Client Referrals:

Partner Referrals:

Infectious Disease Epidemiology, Prevention and Control Division
STD and HIV Section
P.O. Box 64975
625 Robert Street North
St. Paul, Minnesota 55164-0975

651-201-5414; 651-201-5797 TTD Page 4

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