Risk Assessment Screening Questionnaire
All questions require mandatory response:
If patient >= 18 years old
Question | Response Options | Additional Notes |
If you could take a medication that would prevent you from getting HIV, would you be interested? | Yes/No | |
Are you pregnant? | Yes/No | Female Only |
Are you breastfeeding? | Yes/No | Female Only |
Have you had unprotected sex with someone with unknown HIV status since your last HIV test? | Yes/No | |
Have you come into contact with blood or semen or vaginal secretions (including any unprotected sexual encounters) since your last HIV test? | Yes/No | |
Have you had unprotected sex with an HIV positive partner not on ART or with an unknown or elevated viral load? | Yes/No | |
Had more than one sexual partners in the past 12 months? | Yes/No | |
Do you suspect your partner may have multiple sexual partners? | Yes/No | |
Had an STI of any kind in the last 6 months or any current symptoms of STI (sores/warts, discharge, pain, swelling)? | Yes/No | |
Had sex under the influence of alcohol or drugs? | Yes/No | |
Injected drugs, sharing needles, syringes, or other equipment? | Yes/No | |
Exchanged or sold sex for money, goods, or favors in the past 12 months? | Yes/No | |
Do you prefer sex with men or women or both? | Yes/No | |
Have you experienced or do you expect situations that you consider to be risky for acquiring HIV? | Yes/No |
If patient is <18 years old
Question | Response Options | Additional Notes |
Are one or both parents deceased? | Yes/No | Show if age <18 |
Are one or both parents known to be HIV positive? | Yes/No | |
Has the child been admitted to the hospital before? | Yes/No | |
Does the child have recurring skin problem? | Yes/No | |
Has the child had poor health in the last 3 months? | Yes/No | |
Has the child ever had sex? | Yes/No | Hide if age <13 |
TB Screening Logic
Positive
Cough > 14 days
Cough = "Yes" and one of the following
Fever >= 14 days
Night sweats >= 14 days
Unexplained weight loss >= 28 days
Fever >= 14 days and night sweats >= 14 days
Fever >= 14 days and unexplained weight loss >= 28 days
Night sweats >= 14 days and unexplained weight loss >= 28 days
Close contact = "Yes" and patient age <15
Negative
All other responses
Additional Clarifications
All Yes/No responses stall be stored as "Yes"=1, and "No" = 0
Result "Positive" = 1, and "Negative" = 0