Hiv Counseling Information Form Page 2
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3State of California—Health and Human Services Agency
California Department of Public Health
RISK FACTORS
(mark one )
Was client asked about HIV risk factors?
Risk factors discussed
Client was not asked about risk factors
Client declined to discuss risk factors
(1)
(2)
(3)
Number of alcoholic drinks on a
ORAL SEX
VAGINAL OR ANAL SEX
(past 12 months)
typical day when drinking:
(past 12 months)
(0 - 99)
Had vaginal or anal sex with a
Had vaginal or anal
Type of sex:
Had oral sex
(past 12 months, mark all that apply )
Used these drugs:
(mark all that apply )
male …
(mark all that apply )
sex with a male?
with a male?
Stimulants
Heroin
Prescription opioids
(1)
(1)
(1)
without using a condom
(1)
Vaginal receptive
(1)
Yes
Yes
(1)
(1)
Poppers
None of these drugs
(1)
(1)
who injects drugs
(1)
(1)
Anal insertive
No
No
(0)
(0)
who is HIV positive
(1)
Used a needle to inject drugs?
(past 12 months)
Anal receptive
(1)
Declined
(9)
(1)
known to have had sex
Yes
If yes, shared needles or injection
(1)
with a male (if female)
No
equipment?
Yes
No
(0)
(1)
(0)
Had vaginal or anal
Type of sex:
Had vaginal or anal sex with a
Had oral sex
Declined
(9)
(mark all that apply )
(mark all that apply )
sex with a female?
female …
with a female?
Yes
Vaginal insertive
without using a condom
(1)
(1)
(1)
Yes
(1)
Ever used a needle to inject drugs?
(lifetime)
No
Anal insertive
who injects drugs
(0)
(1)
(1)
(1)
Yes
(0)
No
(0)
No
(9)
Declined
(1)
who is HIV positive
Hepatitis C (HCV) diagnosis?
(lifetime)
Had vaginal or anal
Type of sex:
Had vaginal or anal sex with a
Had oral sex
Yes
No
(1)
(0)
(mark all that apply )
sex with a TG?
transgender person …
with a TG?
(mark all)
Vaginal
(past 12 months, mark all that apply )
(1)
STD Diagnosis:
Yes
without using a condom
Yes
(1)
(1)
(1)
Chlamydia
Gonorrhea
Syphilis
Anal insertive
(1)
(1)
(1)
(1)
(0)
No
(1)
who injects drugs
(0)
No
None of these STDs
Anal receptive
(1)
(1)
Declined
who is HIV positive
(9)
(1)
Other HIV behavior/exposure risk?
(past 12 months)
Total number of vaginal or anal sex
Yes
No
(1)
(0)
(specify)
partners:
(past 12 months,1 – 999)
If other HIV behavior/exposure, specify:
Has received money, drugs, or other items or services for sex?
Yes
No
(past 12 months)
(1)
(0)
________________________________________
Has had sex with a person who exchanges sex for drugs or money?
(1)
Yes
(0)
No
(past 12 months)
SESSION ACTIVITIES
OPTIONAL DATA
Optional data:
Risk reduction counseling provided?
Referrals:
Completed hepatitis A (HAV)
(mark all that apply
)
Item 1:
Yes, counseling provided
vaccination series?
(1)
(lifetime)
No referrals
HIV risk reduction activities
(1)
(1)
(2)
No, counseling not offered
Yes
No
(1)
(0)
Pre-exposure prophylaxis
Substance use services
(1)
(1)
Item 2:
(3)
No, client declined
Completed hepatitis B (HBV)
Personal action plan developed?
Syringe services program
STD testing & treatment
(1)
(1)
vaccination series?
(lifetime)
Item 3:
(1)
Yes, plan developed
Hepatitis services
Mental health services
(1)
(1)
Yes
No
(1)
(0)
(2)
No, service not offered
TB testing & treatment
Housing services
(1)
(1)
Item 4:
(3)
No, client declined
PRELIMINARY & CONFIRMED POSITIVE RESULT
Referred to HIV medical care?
If female, is client pregnant?
Yes
If yes, did client attend first appointment?
Yes
If yes, in prenatal care?
(1)
(1)
Appointment date:
Yes
(1)
(mm/dd/yyyy)
No
Yes
(0)
(1)
No
(0)
(8)
Don’t know
(0)
No
Don’t know
(8)
Declined
Don’t know
(9)
(8)
No
If not referred to HIV medical care, indicate why?
(0)
Declined
(9)
Client already in HIV medical care
(1)
Has the unique ID from this testing form been provided to your HIV/AIDS
Client declined HIV medical care
(2)
Surveillance Coordinator or program for inclusion on the HIV/AIDS Adult
Referred to HIV prevention services?
Case Report Form (ACRF)?
Yes
If yes, did client receive HIV prevention services?
(1)
Yes
(1)
(0)
No
(1)
Yes
(0)
No
(8)
Don’t know
No
(0)
PARTNER SERVICES
rd
Were partner services discussed/offered this session?
Was client interviewed for partner elicitation at this agency?
(dual and 3
party)
(mark one )
Interview date:
Number of partners:
(mm/dd/yyyy)
Yes
(1)
rd
(attach Partner Information Forms)
(0-999, dual & 3
party)
Offered and accepted
(1)
No
(0)
Offered and refused
(2)
(3)
Not offered
Was partner services referred out to another agency?
Was skill building provided for self-notification?
Specify agency: ______________________________________________
Yes
(1)
Number of partners to
Yes
Was client interviewed for partner elicitation?
(1)
Number of partners:
No
(0)
be self-notified:
rd
(0-999)
No
Yes
Interview date:
(0)
(1)
(mm/dd/yyyy)
(0-999, dual & 3
party)
No
(0)
Don’t know
(8)
HIV TESTING AND TREATMENT HISTORY
Ever had a previous positive HIV test?
Used or is currently using antiretroviral (ARV) medication?
Date of first positive HIV test:
(mm/dd/yyyy)
Yes
(1)
Yes
(1)
(specify ARV used and indicate first and last date used)
No
(0)
No
(0)
Don’t know
(8)
Don’t know
(8)
Declined to answer
(9)
Declined
(9)
Specify antiretroviral medications: _________________________________
Ever had a negative HIV test?
_______________________________________________________________
Yes
Date of last negative HIV test:
(1)
(mm/dd/yyyy)
Date ARV first began:
(mm/dd/yyyy)
No
(0)
Don’t know
(8)
(if date is from a lab test with test type, enter in lab data section)
Data entry ID:
Declined
(9)
Date of last ARV use:
(mm/dd/yyyy)
Number of negative HIV tests within
(8)
Don't know
24 months before first positive HIV test:
Declined
(9)
CDPH 8458 (07/14)
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