|History of Present Illness|
- What was the date of your first positive HIV test?
- Did you have a previous HIV test? If so, when was the last negative result?
- Where do you usually receive your health care?
- Have you ever received care for HIV?
- What was the date of your last HIV care visit?
- What is your current CD4 (T-cell) count?
- Do you know what your first CD4 count was?
- What was your lowest CD4 count?
- What was your highest CD4 count?
- Do you know what your first viral load count was?
- What is your current viral load count?
- Have you participated in any research protocols?
- What studies, and when?
- Would you be interested in participating in research studies (if available)?
- What opportunistic infection(s) have you had, if any? (PCP, MAC, cryptococcal meningitis, TB, etc.)
- What year(s) were you diagnosed with these infections?
- Have you had cancer(s)?
- What other HIV-related illnesses have you had? Have you had zoster (shingles), oral thrush, pneumonia?
|Active TB and TB Testing History|
- Have you ever had tuberculosis (TB)?
- When was your last TB test?
- Was it a TB skin test (TST) or interferon-gamma release assay (IGRA)?
- What were the results of this test?
- Have you ever had a positive TB result?
- What year and what health care setting?
- What medications did you take and for how long?
|Antiretroviral Therapy (ART) History|
- Are you taking HIV medications now?
- If so, please name them or describe them, and tell me how many times a day you take them.
- How many doses have you missed in the past 3 days?
- The past week?
- The past month?
- What side effects, if any, do you have now? In the past?
- What HIV medicines have you taken in the past (names or descriptions)?
- When did you start and stop taking them (dates)?
- Do you know why you stopped taking these medications?
- Do you know what your HIV viral load or your CD4 counts were while you were taking your medications?
- Have you ever had a resistance test?
- Did you have any side effects to past ARVs?
|Past Medical and Surgical History|
|Chronic Diseases||Do you have any chronic conditions, such as the following? |
If so, do you receive medical care for these conditions?
- High blood pressure
- Heart disease
- Cholesterol problems
- Asthma or emphysema
- Sickle cell disease
- Ulcers, acid reflux, or irritable bowel syndrome
- Thyroid disorders
- Kidney or liver problems
- Mental health disorders
- Have you had any hospitalizations? Where, when, and for what reason?
- Have you had any surgeries? When and where?
- Have you had any major illnesses, including mental health conditions?
- Have you ever had hepatitis? What type (A, B, C)?
- Do you have chronic hepatitis?
- Do you know whether you are immune to hepatitis A or hepatitis B? Have you been vaccinated?
|Gynecologic and Women's Health|
- When was your last cervical Papanicolaou (Pap) test?
- What were the results?
- Have you ever had an abnormal Pap test?
- When was your last menstrual period?
- What is the usual length of your cycle? Is it regular or irregular?
- Have you noticed changes in your menstrual cycle?
- When was your most recent breast examination?
- Have you had a mammogram? When?
- Have you ever had an abnormal breast examination or mammogram?
- Do you get yeast infections? How often?
- Do you get urinary infections?
- Have you ever had kidney stones?
- How many pregnancies have you had?
- How many live births? Ages of children now?
- How many miscarriages or therapeutic abortions?
- Were you tested for HIV during any pregnancy? What year?
- Did you deliver an infant while you were HIV infected?
- Was HIV medication given during pregnancy and delivery?
- Do you have children? What is their HIV status?
- Do you intend to become pregnant?
- Have you ever had an anal Pap test?
- What were the results?
- Have you had anal warts? Other abnormalities?
|Urologic History|| Have you ever had: |
- Kidney stones
- Urinary tract Infections
- Prostate infection or enlargement
- Have you had a prostate-specific antigen (PSA) test? (What were the results?)
|Sexually Transmitted Infections||Have you ever had any of the following infections? |
- Genital herpes
- Nongonococcal urethritis (NGU)
- Genital warts (HPV)
- Pelvic inflammatory disease (PID)
- When was your last oral health examination?
- Do you have all your natural teeth?
- Do you have partials or dentures?
- When was your last vision examination?
- When was your last dilated retinal examination?
- Do you wear glasses or corrective lenses?
- What (non-ARV) medications do you take?
- What herbs, vitamins, nutritional supplements, or over-the-counter (OTC) medications, do you take?
|Allergies; Medication Intolerance|
- Have you had an allergic reaction to any medications? What type of reaction, how severe?
- Have you had allergic reactions to other types of exposures?
- Have you had severe side effects from any medications?
|Immunizations||When was your last vaccination for the following: |
Did you have chickenpox as a child, or were you vaccinated against chickenpox?
- Streptococcal pneumonia (Pneumovax)
- Tetanus/Pertussis (Tdap)
- Hepatitis A
- Hepatitis B
What about measles, mumps, and rubella?
|Health-Related Behaviors||Tobacco use:|
- Do you smoke? How many cigarettes per day? How long have you smoked? How much have you have smoked in the past?
- Besides tobacco, what do you smoke?
- Do you chew tobacco?
- How often do you have a drink containing alcohol? How many drinks do you have on a typical day?
- Have you ever had a problem fulfilling work, social, or school obligations because of alcohol use?
- Do you use any street drugs we haven't covered in earlier questions, or drugs not prescribed to you?
- If so, what drugs and how do you use them (inject, smoke, inhale, etc.)?
- How often do you use substances?
- Have you shared your drug-use equipment with another person?
- What pain relievers do you use on a regular basis?
- Are you interested in treatment for alcohol or drug use?
- What kind of exercise do you participate in? How frequently?
- What do you eat during a typical day?
- Do you consume raw (unpasteurized) milk, raw eggs, raw or rare meat, deli meats, soft cheeses, or raw fish?
- How much water do you drink during a typical day?
- What is your source of water?
- How much caffeine do you drink during a typical day?
|Sensitive Sexual and Gender History Questions|
- Do you consider yourself male or female?
- Have you had or considered treatment for sex change?
- Are you presently taking hormone therapy?
- Have you had hormone therapy in the past?
- Have you had any gender confirmation (sex reassignment) surgery?
- Do you have sex with men, women, or both?
- In the past, have you had sex with men, women, or both?
|Sexual Practices |
- Do you have anal sex? Vaginal? Oral?
- How do you protect yourself from sexually transmitted infections, or HIV reinfection?
- For men who have sex with men: Are you the receptive or insertive partner, or both?
- How often do you use alcohol or drugs before or during sex?
|HIV Prevention |
- Do you know the HIV status of your partner(s)?
- How do you protect your partners from HIV?
- In what situations do you or your partner use condoms or some other barrier?
- Are there situations in which you do not use barrier protection?
- Have you ever exchanged sex for food, shelter, drugs, or money?
- What birth control measures do you use, if any?
- How often do you use condoms or other latex barriers?
- Do you have plans for you or your partner to become pregnant?
| || Do you have a family history of: |
Which family member(s) and what is their health status currently?
- Heart disease? Heart attacks or strokes?
- Cholesterol problems? Diabetes?
- Mental health conditions (e.g., depression, bipolar disorder, anxiety, phobias)?
- What is your relationship status (single, married, partnered, divorced, widowed)?
- Do you have children?
- Do you live alone or with others? With whom?
- Who knows about your HIV status?
- Which individual has been the most supportive since your HIV diagnosis?
- Who has been the least supportive?
- Have you used any community services such as support groups?
- Are you currently employed?
- Where do you work?
- Describe your job task(s).
- What setting do you work in on a daily basis?
- Does your employer provide health insurance?
- Does your employer know of your HIV status?
- If on disability: How long have you been on disability?
- What medical condition has made you disabled?
- Have you ever been incarcerated? When was the last time?
- What kind of pets do you have, and who cleans up after them?
- Where have you traveled outside the United States?
- When did travel take place?
- How do you handle your problems/stresses?
- What do you do to relax?
- Have ever been diagnosed with depression, anxiety, panic, bipolar disorder, schizophrenia, etc.?
- Have you taken or are you taking any medications for these conditions?
- Are you seeing a therapist or mental health professional?
- Have you had any previous counseling or mental health problems?
- Have you ever been hospitalized for a psychiatric condition?
- Have you ever thought about hurting yourself? (If yes, probe for previous suicide attempts: Are you feeling that way now?) (See chapter Suicide Risk and prepare for immediate referral if necessary.)
- Have you ever been sexually abused, assaulted, or raped?
- Has an intimate partner ever forced you to do something you did not want to do?
- Has a partner, family member, or other person ever physically hurt you?
- Have you lived in any situation with physical violence or intimidation?
- When has this occurred?
- Are you afraid for your safety now?
- (If yes) Did you seek legal help, therapy, or other type of assistance?
- Was there any alcoholism or drug abuse in your household when you were a child?
- Did you experience or observe violence; physical, sexual, or emotional abuse; or neglect?