General Medical History

Do you have any allergies that you know of?
Do you have any medical conditions? If so, what are they? How long have you had them?
Have you ever received blood? If yes, when?
Are you taking any medications?
Have you been vaccinated against Hepatitis B?

Contraception

Do you or your partner use any type of birth control? If yes, what? If no, is there a reason?

Pregnancy

Have you (or your partner) ever been pregnant? If yes, how many times? What were the outcomes of those pregnancies?

Current/Past Relationships

Do you have a regular partner? If yes, how long have you been with this person? Is this partner male or female? Have your previous partners been male or female?

Most Recent Sexual Contact

When was your last sexual contact? Was that contact with your regular partner or with another partner? What kind of sex was involved (performing or receiving oral sex, performing or receiving anal or genital penetration)? Was protection used during your most recent sexual contact?

Number of Partners

How may sexual partners have you had in the last 2 months? How many sexual partners have you had in the past year? How many sexual partners have you had in your lifetime?

Sexual Preference

Do you have sex with men, women or both?

Sexual Practices

Have you ever performed or received oral sex? Have you ever performed or received genital penetration? Have you ever performed or received anal penetration?

Survival Sex

Have you ever traded sex for money, shelter, food or drugs? Have you ever paid for sex?

STD Prevention and Condom Use

Do you do anything to protect yourself from STDs? If you were to describe your condom use would you say that you use condoms always, most of the time, sometimes, or never? When you don't use condoms, why do you make the choice not to use them? When you do use condoms have you had any problems with them?

Self-evaluated risk

If you had to rate your risk for STDs, would you say that you are at no risk, low risk, medium risk or high risk?

Screening

Have you ever been tested for STDs or HIV? If yes, when? Do you know what the results were? Have you ever had a pap test? If so, when and do you know what the results were? Have you ever had an abnormal pap test?

Previous STD

Have you ever been told that you have an STD? If yes, when and do you know what it was? Did you receive treatment?

Partners' STD History

Do you know if your partner has ever had an STD?

Signs and Symptoms

Do you have any symptoms that might make you think you have an STD? Do you have any sores on or around your genitals? Does it hurt or burn when you pee? Have you noticed an unusual discharge from your penis, vagina or anus? Do you have pain during sex?

Housing

Do you have a home? If no, where do you sleep? Do you live with anyone?

Sources of Income

How do you earn money? How do you pay for food, shelter, clothes or other needs?

History of Abuse

Has anyone ever hit you? Do you feel threatened or worry about your safety? Has anyone ever forced you to have sex? How old were you the first time you had sex? Was it consensual?

Substance/Alcohol Use

Do you or have you ever used drugs? What drugs do you use? How often do you use drugs? Do you drink alcohol? How often?

Injection Drug Use and Equipment

Have you ever injected drugs? Do you have your own injection equipment? Do you prepare your own drug for injection? Do you use a needle exchange program? Have you ever shared a needle, syringe, cooker, cotton or water - even once?

Other Drug Use Risks

Do you ever snort drugs? Have you ever shared a snorting straw?

Sex Under the Influence

Have you ever had sex under the influence of alcohol or drugs?

Consequences

What effect has drug or alcohol use had on your life? Has your drug or alcohol use caused problems with work? With family? With your health?

Other Percutaneous Risks

Do you have any body piercings? Any tattoos? Where did you have your piercings or tattoos done?