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