| What is your date of birth? |
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| Have you completed this Questionnaire on a previous visit to our Office? |
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| When have you completed this survey before? |
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| In which country were you born? | |
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| Do you consider yourself Black, White, American Indian, Alaska Native or Asian Pacific Islander? (check only one) |
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| Do you consider yourself Hispanic or Latino? |
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| Do you consider yourself Male or Female or Transgender? |
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| Which of the following best describes your sexual orientation? |
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| During the past 12 months, have you had sex with anyone? |
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| During the past 12 months, have you had sex with only males, only females, or both? |
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| During the past 12 months, have you had a main sex partner? |
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| Is your main sex partner male or female? |
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| The last time you had sex with your main partner, what type of sex did you have? (Check all that apply) |
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| The last time you had sex with your main partner, did you or your partner use a condom? |
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| During the past 12 months, have you had sex with someone who is not your main partner or whom you did not consider your main partner at that time? |
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| The last time you had sex with someone who is not your main partner, what type of sex did you have? (Check all that apply) |
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| The last time you had sex with someone who is not your main partner, did you or your partner use a condom? |
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| Have you ever had sex in exchange for money, drugs, or shelter? |
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| Have you ever had sex with someone whom you know had or suspected of having HIV/AIDS? |
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| Have you ever had sex with someone whom you knew was or suspected of being an injecting drug user? |
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| The last time you had sex, did you use an injected drug or alcohol? |
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| The last time you had sex, did you use a non-injected drug or alcohol? |
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| During the past 12 months, has anyone told you that you had a sexually transmitted disease, or STD, for example, herpes, gonorrhea, chlamydia, genital warts? |
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| Have you ever, even once, used a needle to inject a drug that was not prescribed for you? |
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| In the past 12 months, have you ever used a needle to inject a drug that was not prescribed for you? |
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| The last time you used a needle for injecting drugs, where did you get the needle from? |
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| The last time you used a needle for injecting drugs, was it a new or unused needle? (A needle in an unopened package or with an intact seal) |
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| The last time you used a needle to inject drugs, what drug did you inject? |
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| The last time you used a needle to inject drugs, did you know or suspect someone else has used it before? |
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| Have you ever used a needle that you knew or suspected someone else had used before you? |
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| Did you use bleach (or other solutions) to clean the needle before you used it? |
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| The last time you used a needle for injecting drugs, did someone else use the needle after you? |
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| The last time you used a needle for injecting drugs, did you have sex with someone while you were high? |
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| In the past 12 months, have you smoked, sniffed, or taken drugs that you did not inject? |
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| The last time you used drugs that you did not inject, what did you use? (Check all that apply) |
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| How did you use the drug? (Check all that apply) |
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| The last time you used a non-injected drug, did you have sex while you were high? |
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| Since your last interview, have you had sex with anyone? |
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| Since your last interview, have you had sex with only males, only females, or both? |
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| Since your last interview, have you had a main sex partner? |
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| Is your main sex partner, male or female? |
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| The last time you had sex with your main partner, what type of sex did you have? (Check all that apply) |
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| The last time you had sex with your main partner, did you or your partner use a condom? |
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| Since your last interview, have you had sex with someone who is not your main partner or whom you did not consider your main partner at that time? |
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| The last time you had sex with someone who is not your main partner, what type of sex did you have? (Check all that apply) |
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| The last time you had sex with someone who is not your main partner, did you or your partner use a condom? |
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| Since your last interview, have you had sex in exchange for money, drugs, or shelter? |
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| Since your last interview, have you had sex with someone whom you knew had or suspected of having HIV/AIDS? |
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| Since your last interview, have you had sex with someone whom you knew was or suspected of being an injecting drug user? |
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| The last time you had sex, did you use an injected drug or alcohol? |
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| The last time you had sex, did you use a non-injected drug or alcohol? |
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| Since your last interview, has anyone told you that you had a sexually transmitted disease, or STD, for example, herpes, gonorrhea, chlamydia, genital warts? |
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| Since your last interview, have you used a needle to inject a drug that was not prescribed to you? |
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| Since your last interview, have you used a needle that you knew or suspected someone else had used before you? |
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| Did you use bleach (or other solutions) to clean the needle before you used it? |
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| The last time you used a needle for injecting drugs, did someone else use the needle after you? |
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| The last time you used a needle for injecting drugs, did you have sex with someone while you were high? |
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| Since your last interview, have you smoked, sniffed, or taken drugs that you did not inject? |
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