HIV Pre-Test Questionnaire

1
Name* This field is required.
First Name
Last Name
2
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
3
Birthdate / Day of Birth* This field is required.
Date
Month
Day
Year
4
Phone Number* This field is required.
Please enter a valid phone number.
5
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
6
RACE* This field is required.
American Indian
Asian
Black/African American
Native Hawaiian / Pacific Islander
White
Other
7
Ethnicity* This field is required.
Not Hispanic or Latinx
Hispanic or Latinx
Afro-Latinx
Arab / Chaldean
8
Assigned Sex at Birth* This field is required.
Male
Female
Intersex
Other (please specify)
9
Gender Identity - (You may select more than one gender)* This field is required.
Man
Woman
Transgender
Gender Non-Binary
Other
10
Pronouns - (You may select more than one Pronoun)
He / Him
Her / She
They / Them
Other
11
Have you ever been tested for HIV?* This field is required.
Yes
No
12
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.
13
What type of HIV test was your latest HIV test?* This field is required.
Rapid test (finger poke)
Other test
Blood draw (needle in arm)
Not applicable
Oral swab (OraSure or OraQuick)
14
What was the test result of your last HIV test?* This field is required.
Positive
Negative
I didn't receive my result
Not Applicable
15
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
Other
16
Number of sexual partners in the last 30 days* This field is required.
17
Who do you have sex with? (Select all that apply)* This field is required.
Men
Women
Transgender
Gender Non-Binary
Other
18
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
19
How often do you use condoms?* This field is required.
Always
Sometimes
Never
20
What type of sex do you engage in? (Please select all that apply)* This field is required.
Anal Sex
Oral Sex
Vaginal Sex
21
Have you ever had a Sexually Transmitted Infection/Disease (STI/STD)?* This field is required.
Yes
No
22
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
Other
23
When was the last time you were tested for STI/STD?* This field is required.
24
Have you ever used needles to inject recreational drugs?* This field is required.
Yes
No
25
If you have used needles to inject recreational drugs, have you shared needles?* This field is required.
Yes
No
Not applicable
26
Have you been tested for Hepatitis C?* This field is required.
Yes
No
27
Do you currently have health insurance?* This field is required.
Yes
No
28
If Yes, what type of health insurance do you currently have?* This field is required.
Private Insurance
Medicaid
Medicare
No Insurance
29
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
30
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
31
Have you ever used PrEP in the last 12 months?* This field is required.
Yes
No
32
Are you currently taking PrEP?* This field is required.
Yes
No
33
Would you like assistance to access PrEP during your HIV testing session?* This field is required.
Yes
No
34
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
35
Have you ever used PEP in the last 12 months?* This field is required.
Yes
No
36
Do you need assistance in accessing PEP during your HIV testing session?* This field is required.
Yes
No
37
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
38
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
39
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
40
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
41
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
42
Have you ever felt that you should cut down on drinking or any drug use?* This field is required.
Yes
No
43
Have people annoyed you by criticizing your drinking or drug use?* This field is required.
Yes
No
44
Have you ever felt bad or guilty about your drinking or drug use?* This field is required.
Yes
No
45
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
46
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
47
Are you afraid you might be hurt in your apartment building or house?* This field is required.
Yes
No
48
In the last 12 months, did you skip medications to save money?* This field is required.
Yes
No
49
In the last 12 months, have you needed to see a doctor but could not because of cost?* This field is required.
Yes
No
50
Did you put off or neglect going to the doctor because of distance or transportation?* This field is required.
Yes
No
51
Do you have a job?* This field is required.
Yes
No
52
During the last four weeks, have you been actively looking for work?* This field is required.
Yes
No
53
Are you currently in a relationship?* This field is required.
Yes
No
54
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
55
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
56
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: