What HIV/STD prevention methods do you use Do you have access to barrier (For MCM to answer) Can client when having sex? methods (e.g. condoms)? describe the proper use of condoms? Condom Dental dam Saran Wrap Yes No Yes No Latex gloves Withdrawal Other: I may not use barrier methods when: When I am sexually excited When I feel angry or upset When I am with a new partner When I am the top When I am the bottom When I am drinking and/or high When I feel bad about myself Condoms don’t feel good When I am seeking drugs/money When there’s not much risk When I’m undetectable When I’m not expecting sex When my partner pressures me to When my partner(s) are Other: not use condoms positive How often do you disclose your Is there anything about safer sex If yes, describe: HIV status with sexual or sexual risk that you want to partners? know more about? Yes No (For MCM to answer) Is the client of the Michigan HIV If no, did the MCM make client aware of the law? Disclosure law? Yes No Yes No Would you like assistance to Has your partner(s) been tested for HIV? Do you need assistance to access HIV testing? connect with Partner Services? Yes No Yes No Yes No Comments: Social Support and Spirituality Since last (re)assessment, there has been: New Need Continuing Need This is a: No changes Changes Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below. What do you do to socialize? What are your interests? What type of support system do you have? Do you believe you have an adequate support system? None Family Friends Religious group Yes No Support Neighbors Social Media Other: Yes No Have you told anyone about your HIV status? If yes, complete chart below: SUPPORTIVE OF YOU TAKING MEDICATIONS AND NAME OF SUPPORT PERSON RELATIONSHIP TO MEDICAL APPOINTMENTS? Yes No Yes No Yes No Yes No Yes No Who helps you when you are seriously ill? Do you need help to disclose your HIV status? If yes, who? Yes No Is religion/faith/spirituality important to you? If yes, explain: Yes No List 3 strengths or areas in your life. How do these strengths help you deal with your diagnosis?
What HIV/STD prevention methods do you use when having sex? Condom Dental dam Saran Wrap Latex gloves Withdrawal Other: Do you have access to barrier methods (e.g. condoms)? Yes No (For MCM to answer) Can client describe the proper use of condoms? Yes No I may not use barrier methods when: When I am sexually excited When I feel angry or upset When I am with a new partner When I am the top When I am the bottom When I am drinking and/or high When I feel bad about myself Condoms don’t feel good When I am seeking drugs/money When there’s not much risk When I’m undetectable When I’m not expecting sex When my partner pressures me to not use condoms When my partner(s) are Other: How often do you disclose your HIV status with sexual partners? Is there anything about safer sex or sexual risk that you want to know more about? Yes No If yes, describe: (For MCM to answer) Is the client of the Michigan HIV Disclosure law? Yes No If no, did the MCM make client aware of the law? Yes No Would you like assistance to connect with Partner Services? Yes No Has your partner(s) been tested for HIV? Yes No Do you need assistance to access HIV testing? Yes No Comments: Social Support and Spirituality Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below. What do you do to socialize? What are your interests? What type of support system do you have? None Family Friends Religious group Support Neighbors Social Media Other: Do you believe you have an adequate support system? Yes No Have you told anyone about your HIV status? Yes No If yes, complete chart below: NAME OF SUPPORT PERSON RELATIONSHIP SUPPORTIVE OF YOU TAKING MEDICATIONS AND TO MEDICAL APPOINTMENTS? Yes No Yes No Yes No Yes No Yes No Who helps you when you are seriously ill? Do you need help to disclose your HIV status? Yes No If yes, who? Is religion/faith/spirituality important to you? Yes No If yes, explain: List 3 strengths or positive areas in your life. How do these strengths help you deal with your diagnosis?
ELECTRONIC_Standardized_Michigan_HIV_MCM_Reassessment_Pilot_Tool_2_2016_517966_7.docx