Screening Packet

Section C:

In an effort to provide continuity of care and to not provide unnecessary referrals to you, please provide the following information, if applicable.
Name of Mental Health Provider
Name of attorney or legal counselor
Are you currently in other classes or counseling? If so, who ls providing that service?
*Please note, this does not authorize us to contact these providers or release information to them.

If you would like for us to contact them, please let your counselor know and a consent can be completed.*

	Yes	No
Have you seen a doctor or other health care provider in the past 3 months?
Do you live on the street or in a shelter?
Have you ever been in jail?
Have you ever been told you have a positive HIV test [test for the AIDS virus]?
Woman: Have you missed your last two periods
Have you ever had a positive skin test for TB? (a test given with a small injection under the skin on your forearm, a blister will appear if it is (+))
Have you ever been told you have TB or has anybody you know or lived with been diagnosed with TB in the last year?
Within the last 30days, 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 clothes or the sheets on the bed.
Productive Cough
Couching up Blood
Shortness of breath
Lumps or swollen glands in the neck or armpits
Losing weight without meaning to
Diarrhea lasting more than a week
Do you live with someone who has any of the following symptoms?
Couching up blood
Drenching night sweats
Do you know or are you close to anyone with these symptoms?
Do you use needles to shoot drugs?
Do you use coke or crack?
In the last 6 months, have you had any VD's[venereal diseases, STDs, Sexually transmitted diseases], like Syphilis, the clap [Gonorrhea], Chlamydia, or NGU [Nongonococcal Urethritis, Trichomoniasis, trick]?
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?
Rash, spots, or other skin problems, especially on the palms or the soles of the feet?
Women: have you had a vaginal discharge that is different from what you usually have?
Women: Experiencing pain when you have vaginal sex?
Men: Experiencing discharge from the penis?
Have you had a sexual encounter (of any kind) with more than two people -at different times - in the past 6 months? (with or without a condom)
Have you engaged in anal intercourse?
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?
Have you ever been forced yo have sex against your will?

Screening Packet

Case Management Form

Please answer the following questions to help your counselor provide beneficial referrals at your intake.

Section A:

Section B

Section C:

Screening Instrument for Infectious Diseases