Appendix A. Online Risk Assessment Tool - AHRQ National ...

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health with your partner?3 Are your current partner(s) male, female, or both? "Yes" to 2Relationships# Question Prereq Options Script Programming Notes1Are you dating someone or inany kind of sexual relationship? Yes Continue1 Are you dating someone or in any kind of sexual relationship?No Skip to 4Can you discuss concerns youhave about health with your2 partner? Yes Go to 32 Can you discuss concerns you have aboutNoThe only partner-specificquestions we should askwould be from InfectiousDisease domain. Skip to4 below.Are your current partner(s) male,3 female, or both? "Yes" to 2 Male Ask all partner questions3 Are your current partner(s) male, female, or both? "Yes" to 2FemaleOnly partner questionsfrom Infectious DiseasedomainBoth Ask all partner questionsHave you ever been hit, slapped,4kicked, or physically hurt in anyway?YesPhysical/sexualabuse4 Have you ever been hit, slapped, kicked, or physically hurt in any way?No5Has anyone ever made you dosomething sexual that you didn’twant to do?5 Has anyone ever made you do something sexual that you didn’t want to do?No6Have you ever felt nervous orscared because of the things thatsomeone said to you?6 Have you ever felt nervous or scared because of the things that someone said to you?No7Has anyone ever told you thatyou are a bad person, that youare useless or that you are worthnothing?7 Has anyone ever told you that you are a bad person, that you are useless or that you are worth nothing?No8Are you afraid that someone youknow may hurt you?8 Are you afraid that someone you know may hurt you?No9Are you ever afraid or nervous togo home?9 Are you ever afraid or nervous to go home?NoYesYesYesYesYesPhysical/sexualabuseEmotional(Verbal) abuseEmotional(Verbal) abuseDoes not feelsafeDoes not feelsafe2
2 Do you use birth control on a regular basis? "Yes" to 12a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 2Sexual and reproductive health# Question Prereq Sub-Question Options Script(s)ProgrammingNotes1Have you ever had sex,like vaginal intercourse,oral sex, or anal sex?Yes1 Have you ever had sex, like vaginal intercourse, oral sex, or anal sex?NoRegardless ofanswers to #2and 3, doesnot getQuestions 2,3, 4 inInfectiousDiseasedomain. Inthis section,only askQuestions 3,8, 9 belowDo you use birth control2 on a regular basis? "Yes" to 1 Yes Go to 4aNo No Birth Control Go to 5multiple select(provide all2aIf so, what kind? Checkall the types that you usenow. "Yes" to 2Birth controlpillsBirth Control pillscripts - coulddivide betweeninteractions)2a If so, what kind? Check all the types that you use now. "Yes" to 2Birth controlpatchBirth ControlpatchBirth controlringBirth ControlringBirth controlshotBirth Controlshot (depo)MaleCondom Male CondomsFemaleCondomFemaleCondomsWithdrawal WithdrawalDiaphragm DiaphragmTubes tied Tubal ligationIUD IUDAbstinence AbstinenceImplant ImplantVasectomy VasectomySpermicide SpermicideSpermicidewithCondomSpermicide withCondomMorningafter pillPlan B (morningafter pill)2a If so, what kind? Check all the types that you use now. "Yes" to 22a If so, what kind? Check all the types that you use now. "Yes" to 2Other3Rhythm/naturalfamilyplanningRhythm method(natural familyplanning)General BirthControlRecommendations
Page 1: Appendix A: Online Risk Assessment
Page 5 and 6: Sexual and reproductive health (con
Page 7 and 8: 6 Do you take any prescriptions for
Page 9 and 10: Family and genetic history (continu
Page 11 and 12: Psychiatric (continued)# Question P
Page 13 and 14: Immunizations (continued)# Question
Page 15 and 16: Infectious disease (continued)# Que
Page 17 and 18: Infectious disease (continued)# Que
Page 19 and 20: Nutrition and activity# Question Pr
Page 21 and 22: Environmental exposures# Question P

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