Substance Abuse


People who report a history of substance abuse are at a greater risk for developing certain serious communicable diseases. Please answer the following questions to determine if you may need further health assessment.

Section 1: The following questions relate to HIV (the virus that causes AIDS), Hepatitis A, B and/or C and Sexually Transmitted Infections (STIs), e.g., Herpes, Gonorrhea, Syphilis, Chlamydia:

  1. Have you ever had unprotected sex (no condom) or engaged in sexual behaviors (oral, anal or genital) with a person whose HIV/AIDS, Hepatitis or Sexually Transmitted Infection (STI) status is unknown to you? (For example, sex while drunk or high with a person you do not know very well or sex with prostitutes.)
    Yes No

  2. Have you ever engaged in sexual behavior with anyone who has:
    Injected drugs Yes No
    Traded sex for drugs Yes No
    Many sexual partners Yes No
    HIV/AIDS Yes No
    Hepatitis Yes No
    STIs Yes No

  3. Have you ever shared needles or injecting "works" with other individuals including your spouse or significant other, even if just once or a long time ago?
    Yes No

  4. Have you experienced other forms of blood-to-blood or body fluid contact (for example, blood transfusions, hemophilia treatments, employment in medical field), and have concerns about your risk for HIV, Hepatitis or STIs?
    Yes No
Section 2: Individuals who abuse substances are also at risk for contracting tuberculosis (TB). Please answer the following questions to determine if you may need health screening for TB.
  1. Have you recently lived in a substance abuse treatment facility, homeless shelter, drug house, jail, mental hospital or in other close quarters with people you did not know well?
    Yes No
  2. Have you recently had close contact or live with someone diagnosed with or being treated for TB?
    Yes No
  3. Were you born in a area with a high rate of TB (e.g., Asia, Latin America, Africa, India) or recently visited an area with a high rate of TB?
    Yes No
  4. Have you had a nagging cough for more than three weeks along with any of the following symptoms?
    Weight loss Yes No
    Fever for 3 days or longer Yes No
    Night sweats Yes No
    Coughing up blood Yes No


Client Signature Date

Section 3: To be completed by AAR or Treatment Program

Is this individual a high risk candidate for (mark all that apply):
STIs Yes
Hepatitis Yes
TB Yes

If at risk, assist client by identifying applicable health referral resources on Page 3 and GIVE Page 3 to the client.

Public Health (HIV/AIDS, TB, STI Clinic, Hepatitis)
Private Physician Name:
Note: Release of information for communication with primary care provider should be completed. Documentation of refusal to sign release should also be included in record
TB, STI or Hepatitis Hotlines/Resources
Health Care/Indigent Health Assistance/Resources
Other Resources not Listed Specify:

Additional Comments:




AAR or Treatment Staff Signature Date