| Did you receive a transfusion of blood or blood products between 1978 and 1985? |
| Have you ever, even once, used any kind of injected drug? |
| Have you ever had sex with someone who has used injected drugs? |
| For men: Have you ever, even once, had sex with a man or with a prostitute? |
| For women: Have you ever had sex with a bisexual man? |
| Do you have any other reason to suspect that you might be at risk for AIDS or for HIV infection? |
