• What was the date of your first positive HIV test?
• Did you have a previous HIV test? If so, when was the last negative result?

• Where do you usually receive your health care?
• Have you ever received care for HIV?
• What was the date of your last HIV care visit?
• What is your current CD4 (T-cell) count?
• Do you know what your first CD4 count was?
• What was your lowest CD4 count?
• What was your highest CD4 count?
• Do you know what your first viral load count was?
• What is your current viral load count?

• What opportunistic infection(s) have you had, if any? (PCP, MAC, cryptococcal meningitis, TB, etc.)
• What year(s) were you diagnosed with these infections?
• Have you had cancer(s)?
• What other HIV-related illnesses have you had? Have you had zoster (shingles), oral thrush, pneumonia?

• Have you ever had tuberculosis (TB)?
• When was your last TB test?
• Was it a TB skin test (TST) or interferon-gamma release assay (IGRA)?
• What were the results of this test?
• Have you ever had a positive TB result?
• What year and what health care setting?
• What medications did you take and for how long?

• Are you taking HIV medications now?
• If so, please name them or describe them, and tell me how many times a day you take them.
• How many doses have you missed in the past 3 days?
• The past week?
• The past month?
• What side effects, if any, do you have now? In the past?
• What HIV medicines have you taken in the past (names or descriptions)?
• When did you start and stop taking them (dates)?
• Do you know why you stopped taking these medications?
• Do you know what your HIV viral load or your CD4 counts were while you were taking your medications?
• Have you ever had a resistance test?
• Did you have any side effects to past HIV medications?

Do you have any chronic conditions, such as the following?

• Diabetes
• High blood pressure
• Heart disease
• Cholesterol problems
• Asthma or emphysema
• Sickle cell disease
• Ulcers, acid reflux, or irritable bowel syndrome
• Thyroid disorders
• Kidney or liver problems
• Mental health disorders

If so, do you receive medical care for these conditions?

• Have you had any hospitalizations? Where, when, and for what reason?
• Have you had any surgeries? When and where?
• Have you had any major illnesses, including mental health conditions?

• Have you ever had hepatitis? What type (A, B, C)?
• Do you have chronic hepatitis?
• Do you know whether you are immune to hepatitis A or hepatitis B?
  Have you been vaccinated?

• When was your last cervical Papanicolaou (Pap) test?
• What were the results?
• Have you ever had an abnormal Pap test?
• When was your last menstrual period?
• What is the usual length of your cycle? Is it regular or irregular?
• Have you noticed changes in your menstrual cycle?
• When was your most recent breast examination?
• Have you had a mammogram? When?
• Have you ever had an abnormal breast examination or mammogram?
• Do you get yeast infections? How often?
• Do you get urinary infections?
• Have you ever had kidney stones?

• How many pregnancies have you had?
• How many live births? Ages of children now?
• How many miscarriages or therapeutic abortions?
• Were you tested for HIV during any pregnancy? What year?
• Did you deliver an infant while you were HIV infected?
• Was HIV medication given during pregnancy and delivery?
• Do you have children? What is their HIV status?
• Do you intend to become pregnant?

• Have you ever had an anal Pap test?
• What were the results?
• Have you had anal warts? Other abnormalities?

Have you ever had:

• Kidney stones
• Urinary tract Infections
• Prostate infection or enlargement
• Have you had a prostate-specific antigen (PSA) test? (What were the results?)

Have you ever had any of the following infections? If yes, when was last episode?

• Syphilis (If yes, ask about stage, treatment and date of treatment, titer follow-up, and date and result of last titer.)
• Vaginitis
• Genital herpes
• Nongonococcal urethritis (NGU)
• Gonorrhea (If yes, ask about sites of infection: oral, anal, urethral, vaginal.)
• Chlamydia (If yes, ask about sites of infection: oral, anal, urethral, vaginal.)
• Genital warts (HPV)
• Proctitis
• Pelvic inflammatory disease (PID)
• Trichomoniasis

• When was your last oral health examination?
• Do you have all your natural teeth?
• Do you have partials or dentures?

• When was your last vision examination?
• When was your last dilated retinal examination?
• Do you wear glasses or corrective lenses?

• What (non-ARV) medications do you take?
• What herbs, vitamins, nutritional supplements, or over-the-counter (OTC) medications, do you take?

• Have you had an allergic reaction to any medications? What type of reaction, how severe?
• Have you had allergic reactions to other types of exposures?
• Have you had severe side effects from any medications?

When was your last vaccination for the following:

• Streptococcal pneumonia (Pneumovax; PPV23, PCV13)
• Tetanus/Pertussis (Tdap)
• Influenza
• Hepatitis A
• Hepatitis B

Did you have chickenpox as a child, or were you vaccinated against chickenpox?

What about measles, mumps, and rubella?

Tobacco use:

• Do you smoke? How many cigarettes per day? How long have you smoked? How much have you have smoked in the past?
• Besides tobacco, what do you smoke?
• Do you chew tobacco?

Alcohol use:

• How often do you have a drink containing alcohol? How many drinks do you have on a typical day? How many per week?
• Have you ever had a problem fulfilling work, social, or school obligations because of alcohol use?
• Have you ever sought treatment for alcohol-related problems?

Drug use:

• Do you use any recreational or street drugs we haven't covered in earlier questions? Any prescription drugs or medications that were not prescribed to you?
• If so, what drugs and how do you use them (inject, smoke, inhale, etc.)?
• How often do you use substances?
• Have you shared drug-use equipment with another person?
• What pain relievers do you use on a regular basis?
• Are you interested in treatment for alcohol or drug use?
• Have you ever sought treatment?

Exercise:

• What kind of exercise do you participate in? How frequently?

Diet:

• What do you eat during a typical day?
• Do you consume raw (unpasteurized) milk, raw eggs, raw or rare meat, deli meats, soft cheeses, or raw fish?
• How much water do you drink during a typical day?
• What is your source of water?
• How much caffeine do you drink during a typical day?

• Do you consider yourself male or female?
• Have you had or considered treatment for sex change?
• Are you presently taking hormone therapy?
• Have you had hormone therapy in the past?
• Have you had any gender confirmation (sex reassignment) surgery?

• Do you have sex with men, women, or both?
• In the past, have you had sex with men, women, or both?
• In the past 2 months, how many sex partners have you had?
• In the past 12 months, how many sex partners have you had?

• Do you have anal sex? Vaginal? Oral?
• How do you protect yourself from sexually transmitted diseases, or HIV reinfection?
• For men who have sex with men:
• Are you the receptive or insertive partner, or both?
• How often do you use alcohol or drugs before or during sex?

• Do you know the HIV status of your partner(s)?
• Do you take measures to protect your partners from HIV? What measures?
• In what situations do you or your partner use condoms or some other barrier?
• Are there situations in which you do not use barrier protection?

• Have you ever exchanged sex for food, shelter, drugs, or money?

• What birth control measures do you use, if any?
• How often do you use condoms or other latex barriers?
• Do you have plans for you or your partner to become pregnant?

Do you have a family history of:

• Heart disease? Heart attacks or strokes?
• Cholesterol problems? Diabetes?
• Cancer?
• Mental health conditions (e.g., depression, bipolar disorder, anxiety, phobias)?
• Addictions?

Which family member(s), and what is their health status currently?

• What is your relationship status (single, married, partnered, divorced, widowed)?
• Do you have children?
• Does your partner (and/or children) know about your HIV status?

• Do you live alone or with others? With whom?
• How long have you lived in your residence?

• Who knows about your HIV status?
• Which individual has been the most supportive since your HIV diagnosis?
• Who has been the least supportive?
• Have you used any community services such as support groups?

• Are you currently employed?
• Where do you work?
• Describe your job task(s).
• What setting do you work in on a daily basis?
• Does your employer provide health insurance?
• Does your employer know of your HIV status?
• If on disability: How long have you been on disability?
• What medical condition has made you disabled?

• Have you ever been incarcerated? When was the last time?

• What kind of pets do you have, and who cleans up after them?

• Where have you traveled outside the United States?
• When did travel take place?

• How do you handle your problems/stresses?
• What do you do to relax?

• Have ever been diagnosed with depression, anxiety, panic, bipolar disorder, schizophrenia, etc.?
• Have you taken or are you taking any medications for these conditions?
• Are you seeing a therapist or mental health professional?
• Have you had any previous counseling or mental health problems?
• Have you ever been hospitalized for a psychiatric condition?
• Have you ever thought about hurting yourself? (If yes, probe for previous suicide attempts: Are you feeling that way now?) (See chapter Suicide Risk and prepare for immediate referral if necessary.)

• Have you ever been sexually abused, assaulted, or raped?
• Has an intimate partner ever forced you to do something you did not want to do?
• Has a partner, family member, or other person ever physically hurt you?
• Have you lived in any situation with physical violence or intimidation?
• When has this occurred?
• Are you afraid for your safety now?
• (If yes) Did you seek legal help, therapy, or other type of assistance?

• Was there any alcoholism or drug abuse in your household when you were a child?
• Did you experience or observe violence; physical, sexual, or emotional abuse; or neglect?