1. Are you sexually active?
   Yes    No
2. Do you have a sexually transmitted disease, such as syphilis, herpes, chlamydia or gonorrhea?
   Yes    No
3. Have you even once had unprotected sex with someone who was not proven to be HIV-negative?
   Yes    No
4. Have you ever had sex while under the influence of alcohol or other drugs?
   Yes    No
5. Do you use intravenous (injected) drugs?
   Yes    No
6. Have you even once shared or reused a needle used by someone else?
   Yes    No
7. Do you have contact in your work or elsewhere with body fluids such as blood, semen, organs or tissue from other people and do not always take precautions when handling them?
   Yes    No
8. Have you received a blood transfusion or other blood products prior to 1985?
   Yes    No

Sources