HIV Pre-Test Questionnaire

1
What type of testing will you be doing?* This field is required.
HIV Drive Thru Testing - This is for people who have vehicles.
HIV Contactless Testing - This is for people who do not have a vehicle and must do the testing in-person.
HIV At-Home Testing - This option is only for individuals that have received an At-Home testing kit.
2
What testing option would you like during your testing session? (No matter which option you choose, your HIV testing session will be kept confidential.)* This field is required.
CONFIDENTIAL - HIV testing results will be given verbally AND with a paper documentation that you can keep for your records.
ANONYMOUS - HIV testing results will be given verbally only.
3
Name* This field is required.
First Name
Last Name
4
Address - If you are homeless, please type "Homeless" in the Street Address. Provide the city, state, and zip code of the area that you are often located.* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Birthdate / Day of Birth* This field is required.
Date
Month
Day
Year
6
Phone Number* This field is required.
Please enter a valid phone number.
7
Email - (Optional, if you do not have a working phone number, please provide your email so we can contact you about the testing process. You will also receive a copy of this form if you provide an email.)
example@example.com
8
Social Media Contact Information - (Optional - If you DO NOT have an email or phone number, please provide your social media contact information so we may contact you about your appointment. We do not use this information for any other purposes other than contacting you about your appointment and any other services that you request from our agency.)
9
RACE* This field is required.
American Indian
Asian
Black/African American
Native Hawaiian / Pacific Islander
White
10
Ethnicity* This field is required.
Not Hispanic or Latinx
Hispanic or Latinx
Afro-Latinx
Arab / Chaldean
11
Assigned Sex at Birth* This field is required.
Male
Female
12
Gender Identity - (You may select more than one gender)* This field is required.
Man
Woman
Transgender
Gender Non-Binary
13
Pronouns - (You may select more than one Pronoun)
He / Him
Her / She
They / Them
14
Have you ever been tested for HIV?* This field is required.
Yes
No
15
When did you last get tested for HIV? (Please type the closest day, month, and year. Type NA for Not Applicable)* This field is required.
16
Where did you last get tested for HIV?* This field is required.
Lansing Area AIDS Network
Planned Parenthood
Health Department
Doctor's Office
Not Applicable
17
What was the test result of your last HIV test?* This field is required.
Positive
Negative
I didn't receive my result
Not Applicable
18
Please select any situation(s) that may apply to you - (Select all that apply - SKIP if these questions do not apply to you)
Exchange sex for money or drugs
Incarcerated
Sex against your will
Migrant Worker
19
What is your relationship status - (You may select more than one relationship status)* This field is required.
Single
Married
Partnered - Open Relationship
Partnered - Closed Relationship
Polyamorous
20
Number of sexual partners in the last 30 days* This field is required.
21
Number of sexual partners in the last year* This field is required.
22
Who do you have sex with? (Select all that apply)* This field is required.
Men
Women
Transgender
Gender Non-Binary
23
What are your current/past partner(s) HIV status? (Select all that apply)* This field is required.
Positive - Undetectable
Positive - Dectectable
Positive - Unsure of Viral Load Status
Negative
I Do Not Know
24
How often do you use condoms?* This field is required.
Always
Sometimes
Never
25
What type of sex do you engage in? (Please select all that apply)* This field is required.
Anal Sex
Oral Sex
Vaginal Sex
26
Have you ever had a Sexually Transmitted Infection/Disease (STI/STD)?* This field is required.
Yes
No
27
What type of STI/STD have you been exposed to? (Select all that apply)* This field is required.
Chlamydia
Gonorrhea
Herpes
HPV / Genital Warts
Syphilis
Trichomoniasis (aka- Trick)
Not Applicable
28
When was the last time you were tested for STI/STD?* This field is required.
29
Have you ever used needles to inject recreational drugs?* This field is required.
Yes
No
30
If you have used needles to inject recreational drugs, have you shared needles?* This field is required.
Yes
No
Not applicable
31
Have your current/past partner(s) ever used needles to inject recreational drugs?* This field is required.
Yes
No
32
If your current/past partner(s) have used needles, have they shared needles?* This field is required.
Yes
No
Not applicable
I Do Not Know
33
Have you been tested for Hepatitis C?* This field is required.
Yes
No
34
Have you been vaccinated / immunized for Hepatitis A?* This field is required.
Yes
No
35
Do you currently have health insurance?* This field is required.
Yes
No
36
If Yes, what type of health insurance do you currently have?* This field is required.
Private Insurance
Medicaid
Medicare
No Insurance
37
If you do not have health insurance, would you like for us to assist you with accessing health insurance?* This field is required.
Yes
No
Not Applicable
38
Do you have a Primary Care Physician / Doctor that you are currently seeing?* This field is required.
Yes
No
39
If Yes, please type your doctor/physician name or their practice. (We do not report your test results with your doctor. This information is to help us engage with physicians in the local area to provide quality care to their clients when it comes to HIV.)
40
Have you heard of PrEP (Pre-Exposure Prophylaxis)? (PrEP is a pill that helps prevent HIV infection when taken daily.)* This field is required.
Yes
No
41
Have you ever used PrEP in the last 5 years?* This field is required.
Yes
No
42
Have you ever used PrEP in the last 12 months?* This field is required.
Yes
No
43
Are you currently taking PrEP?* This field is required.
Yes
No
44
Are you interested in PrEP?* This field is required.
Yes
No
45
Would you like assistance to access PrEP during your HIV testing session?* This field is required.
Yes
No
46
Have you heard of PEP (Post-Exposure Prophylaxis)? (PEP is a combination of pills that helps prevent HIV infection when taken within hours of potential exposure to HIV.)* This field is required.
Yes
No
47
Have you ever used PEP in the last 12 months?* This field is required.
Yes
No
48
Do you need assistance in accessing PEP during your HIV testing session?* This field is required.
Yes
No
49
Feeling nervous, anxious, or on edge* This field is required.
0 - Not at all
1 - Maybe once a week
2 - Almost every other day
3 - Nearly every day
50
Not being able to stop or control worrying* This field is required.
0 - Not at all
1 - Maybe once a week
2 - Almost every other day
3 - Nearly every day
51
Little interest or pleasure in doing things* This field is required.
0 - Not at all
1 - Maybe once a week
2 - Almost every other day
3 - Nearly every day
52
Feeling down, depressed, or hopeless* This field is required.
0 - Not at all
1 - Maybe once a week
2 - Almost every other day
3 - Nearly every day
53
Thoughts that you want to harm yourself or have attempted to harm yourself* This field is required.
0 - Not at all
1 - Maybe once a week
2 - Almost every other day
3 - Nearly every day
54
Have you ever felt that you should cut down on drinking or any drug use?* This field is required.
Yes
No
55
Have people annoyed you by criticizing your drinking or drug use?* This field is required.
Yes
No
56
Have you ever felt bad or guilty about your drinking or drug use?* This field is required.
Yes
No
57
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?* This field is required.
Yes
No
58
Are you worried or concerned that in the next 2 months you may not have stable housing that you own, rent, or stay in as a part of a household?* This field is required.
Yes
No
59
Are you afraid you might be hurt in your apartment building or house?* This field is required.
Yes
No
60
In the last 12 months, did you skip medications to save money?* This field is required.
Yes
No
61
In the last 12 months, have you needed to see a doctor but could not because of cost?* This field is required.
Yes
No
62
Did you put off or neglect going to the doctor because of distance or transportation?* This field is required.
Yes
No
63
Do you have a job?* This field is required.
Yes
No
64
During the last four weeks, have you been actively looking for work?* This field is required.
Yes
No
65
Are you currently in a relationship?* This field is required.
Yes
No
66
If you are currently in a relationship(s), have arguments in your relationship(s) escalated into any of the following: destruction of property, grabbing, restraining, pushing, kicking, slapping, punching, threats of violence, or other acts of physical intimidation?* This field is required.
Yes
No
Not Applicable
67
If you are currently in a relationship, has your partner(s) pressured or forced you to do something sexual that you did not want to do?* This field is required.
Yes
No
Not Applicable
68
If you are currently in a relationship, has your partner(s) insulted, criticized, threatened, or yelled at you in any way?* This field is required.
Yes
No
Not Applicable
Should be Empty: