Hiv Testing Consent
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1
2Patient Risk Assessment Form
Today’s
Date of Birth:
Date:
Male
County & State where you live:
Current Gender:
Female
County
State
Transgender M-F
Transgender F-M
American Indian/Alaska Native
White
Hispanic/Latino
Race
Asian
Don’t Know
Non-Hispanic/Non-Latino
Ethnicity
(check
Black/African American
Prefer Not
Refuse to Answer
all that
Don’t Know
Answer
apply)
Native Hawaiian/Pacific Islander
Have you had vaginal or anal sex:
Ever?
In the past year (12 months)?
With a Male?
With a Female?
Without using a condom?
With a person who injects drugs?
With a man who has sex with other men?
With a person who is HIV positive?
In exchange for drugs/money/something you
needed?
While drunk or high on drugs?
With an anonymous partner?
With someone you met online?
Never
When was the last time you injected street drugs?
In the last 12 months (1 year)
1 to 4 years ago
4-10 years ago
More than 10 years ago
Never
How often do you inject street drugs?
At least every day
At least once per week
At least once per month
Less than once per month
Yes
No
Do you share drug injection equipment
Doesn’t Apply
(needles/works)?
Yes No
Negative
Have you ever had an HIV/AIDS test before?
Positive
Month______
If yes, when was your last test?
Indeterminate
What was the result of that test?
Don’t Know
Year________
Office Use Only
Site ID
Counselor Number
Test Number:
Type of Test
English as Primary Language?
Yes, (Speaks/Understands English)
No (Interpreter Services Used)
Screening
Targeted Testing
Declined Testing
During this visit, was a risk reduction plan developed
Blood Draw
Other:
for the client? Yes No
Don’t want to know
Anonymous Test
Last Letter of
Last Letter of
First Name
Last Name
OVER
CTR Program
Rev 11/07
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Parent category: Legal