Do you think you need to lose or gain weight?
Do you often feel sad, down, or hopeless?
Do you have friends or family members who smoke in your house?
Do you often spend time outdoors without sunscreen or other protection such as a hat or shirt?
Do you smoke cigarettes or cigars or use any other kinds of tobacco?
Do you use any drugs or medicines to go to sleep, relax, calm down, feel better, or lose weight?
Do you often have more than two drinks containing alcohol in 1 day?
Do you think you or your partner could be pregnant?
Do you think you or your partner could have a sexually transmitted disease?
Have you or your partner(s) had sex without using birth control in the last year?
Have you or your partner(s) had sex with other people in the past year?
Have you or your partner(s) had sex without a condom in the past year?
Have you ever been forced or pressured to have sex?
Have you ever been hit, slapped, kicked, or physically hurt by someone?
Do you have other questions or concerns about your health? (Please identify.)
Source: State of California Office of Clinical Preventive Medicine