Wyoming Department Of Health - Communicable Disease Hiv, Hepatitis And Std Risk Assessment Page 2
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4Wyoming Department of Health – Communicable Disease HIV, Hepatitis and STD Risk Assessment
Please select boxes pertaining to you (check all that apply)
History of blood exposure (under skin or mucous
Injection drug use (even one time)
membranes)
Type of drug(s):_______________
Born between 1945-1965 (Baby Boomer)
Condom Use:
With Main Partner:
Recipient of clotting factor or blood concentrates
Always
prior to 1987
Sometimes
Never
Recipient of blood transfusions, blood components
With Other Partner(s):
or organ transplants prior to 1992
Always
Sometimes
Tattoos, Date(s): _______________
Never
Type:
With New Partner (within last 3 months):
Professional setting
Always
Unprofessional setting
Sometimes
Other:_______________
Never
With Previous Partner:
Symptoms (check all that apply):
Always
Sometimes
Yellowing of the skin
Never
Clay-colored stools
Infected with HIV
Abnormal penile or vaginal discharge
Born in Asia, Africa or South America
Penile, vaginal, anal or oral warts, sores or lesions
Parents born in Asia, Africa or South America
Pain or burning with urination
Current or history of hemodialysis
Increased frequency of urination
Receiving chemotherapy or other
immunosuppressive therapy
Pain or bleeding with sexual intercourse
Current or history of incarceration
Abdominal or pelvic pain
Current or history of homelessness
Penile, vaginal, or rectal itching
History of prior STDs or Hepatitis
Abnormal bleeding
History of working in a health care setting
Night Sweats
Consistently abnormal liver tests
Fever
Mother positive for HIV, STDs, Hepatitis B or C
Rash, generalized or on hands/feet
Sex with:
Anonymous Partner
Other
Partner met via internet
List: _________________________
Sex while:
Intoxicated
If you have selected any of these boxes, you are strongly
High
encouraged by the Wyoming Department of Health to be
In public
tested for: STDs, HIV, and Viral Hepatitis.
Sex in exchange for:
Drugs
Money
Food
Shelter
Client Initials: _________________
June 23, 2016
Page 2
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