Screening for Infectious Diseases in the Substance Abuse Service Setting

1. Have you seen a doctor or other health care provider in the past 3 months? (yes/no)

2. a. Do you live on the street on in a shelter? (yes/no)
   b. Have you ever been in jail? (yes/no)

3. Have you ever been told you have a positive HIV test [test for the AIDS virus]? (yes/no)

4. Women: Have you missed your last two periods? (yes/no)

5. Have you ever had a positive skin test for TB? I mean a test where you got a shot in the forearm, and a few days later had a hard bump like a blister appear? (yes/no)

6. Have you ever been told you have TB? Has anybody you know or have lived with been diagnosed with TB in the past year? (yes/no)

7. a. Within the last 30 days, have you had any of the following symptoms lasting for more than 2 weeks?

   	Fever
   	Drenching night sweats that were so bad you had to change your clothes or the sheets on the bed
   	Productive cough
   	Coughing up blood
   	Shortness of breath
   	Lumps or swollen glands in the neck or armpits
   	Losing weight without meaning to
   	Diarrhea (runs) lasting more than a week

   
   b. Do you live with someone who has any of the following symptoms?

   	Coughing up blood
   	Drenching night sweats

   
   c. Do you know or are you close to anyone with these symptoms? (yes/no)

8. Do you use needles to shoot drugs? (yes/no)

9. Do you use coke or crack? (yes/no)

10. In the last 6 months, have you had any VDs [venereal diseases, STDs, sexually transmitted diseases], like syphilis, the clap [gonorrhea], chlamydia, or NGU [nongonococcal urethritis, trichomoniasis, trick]? (yes/no)

11. Have you, or anyone you've had sex with, had any of the following symptoms within the last 30 days?

    	Sore or ulcer on the penis/vagina ["down there"]?
    	Rash, spots, or other skin problems, especially on your palms or the soles of your feet?

    Women:

    	A vaginal discharge that is different from what you usually have?
    	Pain when you have vaginal sex?

    Men:

    	Discharge from the penis?

12. Have you had sex with more than two people--at different times--in the past 6 months? I mean any type of vaginal, rectal, or oral contact, like you went down on your partner or he/she went down on you, with or without a condom. (yes/no)

13. Have you used your rectum for sex? (yes/no) [Use regionally appropriate terminology to indicate penile penetration, as opposed to other types of sexual contact.]

14. In the past 6 months, have you had sex with someone in return for anything, like money, alcohol or other drugs, a place to stay, or just to survive? (yes/no)

15. Have you ever been forced to have sex against your will? (yes/no)

Note. From Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Disease: Treatment Improvement Protocol Series-11 (DHHS Publication No. {SMA} 94-2094, p. 21), by the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 1994. Veterans Health Administration