RISK ASSESSMENT

A: CLINTELE PROFILE
Sex:

Male Female
Nationality

Swazi Citizen
Temporary Resident in Swaziland
Non -resident
Age group in yrs

< 14
15-19
20-29
30-39
40-49
50-59
60 +
Education:
 

None
Primary school
Secondary Schools
High School
College/University
Occupation:

Unemployed/Housewife
Self-employed
Professionals
Uniformed sources
Artisan
Labourer
Scholar
Pastor
Marital Status:
 

Married
Single
Widow
Divorced
Reasons for Counselling/Testing - Check all that apply

Just curious
Scholarship/insurance
Symptomatic Self/partner
Referred
Partner unfaithful
Partner/Relative died of AIDS
Wants to get married
Considering pregnancy
Partner sick
Rape victim
Partner died of TB

Knowledge on HIV/AIDS (Tick all that apply)




Incurable deadly condition
Sexually Transmissible
HIV causes AIDS
Has enough knowledge
No knowledge
Possible Risk of Exposure
 

(a) Blood Transfusion
Yes
No

(b) Injection/skin cut outside of health facility
Yes
No

(c) History of STDs
Yes
No

(d) Occurrence of STDs (Check all that apply)
Sores
Discharge
Warts
Herpes
Crabs
Thrush

(e) Period of last STD infection
During last 12 months
More than 12 months
Not applicable

(f) Unprotected Sex before or outside marriage
Yes
No

(g) Number of life-time sex partners
0
1
2-4
5-10
11-15
16+


(h) Health status of partner (current & former)
Died of AIDS
Died of TB
Died of other
Partner looks well/alive
Not applicable
Condom usage
 

Always use
Never use
Often use
Started last year
Seldom use
Your Health Status in the past 12 months
 

Severe weight loss (not due to dieting)
Itchy skin rash
Has/Had herpes zooster
History of TB
Prolonged diarrhea
Swelling/edema on extremities
Thrush
Constant and continuous Tiredness
Fever/Cough
No Symptoms