Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone—such as visiting a doctor’s office or shopping?  Yes  No If you have ever been in juvenile/adult detention, jail, or prison for more than 3 days, how long has it been since you last got out?  Never in juvenile/adult detention, jail, or prison for more than 3 days  Less than two years  Two years or more Have you ever served in the Armed Forces, in the Reserves, or the National Guard [select all that apply]?  No (Skip to #14)  Yes, in the Armed Forces  Yes, in the Reserves  Yes, in the National Guard 13a. Are you currently on active duty in the Armed Forces, in the Reserves, or the National Guard?  Yes, in the Armed Forces  Yes, in the Reserves  Yes, in the National Guard  No, separated or retired from Armed Forces, Reserves, or National Guard 13b. Have you ever been deployed to a combat zone [select all that apply]?  Never deployed  Iraq or Afghanistan (e.g., Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn)  Persian Gulf (Operation Desert Shield or Desert Storm)  Vietnam/Southeast Asia  Korea  WWII  Deployed to a combat zone not listed above (e.g., Somalia, Bosnia, Kosovo) Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves or the National Guard, or separated or retired from the Armed Forces, the Reserves, or the National Guard?  No (Skip to #16)  Yes, 1 person  Yes, 2 people  Yes, 3 people  Yes, 4 people  Yes, 5 people  Yes, 6 or more people If yes, answer the following questions for each person you marked in question 17 (up to six people). Service Member #1 Service Member #2 Service Member #3 Service Member #4 Service Member #5 Service Member #6 Service member’s relationship to you: Mother/father Brother/sister Spouse/partner Child Other, specify End of Section
If they have sex while high on drugs or under the influence of alcohol?  No risk  Slight risk  Moderate risk  Great risk If they share unsanitized needles or works when using drugs?  No risk  Slight risk  Moderate risk  Great risk Now think about your relationship with your PRIMARY (MAIN) partner. How confident are you that you could… Refuse to have sex with your partner because you weren’t in the mood?  Not at all  A little  Somewhat  Very much Ask your partner to wait while you got a condom or dental dam?  Not at all  A little  Somewhat  Very much Tell your partner how to treat you sexually?  Not at all  A little  Somewhat  Very much Refuse to engage in sexual practices you didn’t like?  Not at all  A little  Somewhat  Very much Ask your partner to use a condom or dental dam?  Not at all  A little  Somewhat  Very much Refuse to have sex because your partner did not want to use a condom or dental dam?  Not at all  A little  Somewhat  Very much HIV/AIDS – What You Know In Questions 31 – 35, please indicate whether you think each of the following two statements about HIV/AIDS is true or false or if you don’t know. Only people who look sick can spread HIV/AIDS?  True  False  Don’t know Only people who have sexual intercourse with gay (homosexual) people get HIV/AIDS.  True  False  Don’t know Birth control pills protect women from getting HIV/AIDS.  True  False  Don’t know There are drugs available to treat HIV that can lengthen the life of a person infected with the virus.  True  False  Don’t know There is no cure for AIDS.  True  False  Don’t know