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