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SOCIAL HISTORY

FORM 003

Please complete the following information by placing a check mark in the appropriate box(es) or by filling in the requested information.

Do you live:
Alone
with Spouse/Family
With others
Have you ever used any of the following substances? Please check all that apply.
Are you sexually active?
If yes, with:
Men Only
Women Only
Both
Sexual preference:
Top
Bottom
Verse
Have you ever had a sexually transmitted infection/STI/STD?
Yes
No
Was it treated?
Yes
No
Have you ever had sex either?
Vaginal
Oral
Anal
Do you use a contact barrier such as a condom?
Never
Sometimes
Most of the times
Always
Do you have more than one sexual partner?
Yes
No
Have you ever had sex with someone you did not know or with anyone you know to be HIV positive?
Do you ever inject a needle or “works” that are not yours exclusively?
Yes
No
Have you ever had sex in exchange for other things like money, drugs or a place to sleep?
Yes
No
Are you a women or a man who is trying to conceive a child with a partner who is HIV positive?
Yes
No
Are you having any sexual problems?
Yes
No
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