Utah AIDS Foundation HIV/STI Test Site Intake
Legal Name
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First Name
Last Name
Preferred Name
Pronouns
Date of Birth
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-
Month
-
Day
Year
Date
Are you between the age of 18 and 34?
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Yes
No
Phone Number
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Please enter a valid phone number.
Email
*
example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have health insurance? / ¿Usted tiene seguro?
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Yes/Si
No
Ethnicity / Grupo ètnico:
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Hispanic/Hispano, Latino
Not Hispanic/No Hispano, Latino
Don't know/No Sè
Race/Raza:
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American Indian/Alaska Native – Indígena Americano
Asian/Asian American - Asiático/Asiático Americano
Black/African American – Negro/Afroamericano
White/European American –Blanco/Euroamericano
Hawaii Native/Pacific Islander – Nativo de Hawaii/Isl. Del Pac
Don’t Know/No Sé
Sex assigned at birth / Sexo:
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Male/Varon
Female/Hembra
Prefer not to answer
Gender / Género
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Man/Hombre
Woman/Mujer
Non-Binary/No binario (a)
Transgender
Other
Who do you have sex with? / ¿Usted tiene relaciones sexuales con? Check all that apply.
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Men/Hombres
Women/Mujeres
Transgender and Non-binary people
Other
What types of sexual encounters do you have?
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Vaginal Receiving
Vaginal Giving
Anal Receiving
Anal Giving
Oral Receiving
Oral Giving
In the past 12 months have you used injection drugs?
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Yes
No
UAF participates in a Syringe Exchange Program. Would you like any injection supplies? (Syringes, cookers, containers, etc.) All are free, but please note you must have at least one used syringe to exchange for new supplies.
Yes
No
In the past 12 months, have you bought, sold or traded sexual services for money or something else you needed?
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Yes
No
Would you like to talk with someone on how to reduce your risks for HIV/STIs while buying, selling, or trading sexual services?
Yes
No
In the past 12 months, have you or any of your sexual partners tested positive for Gonorrhea or Syphilis?
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Yes
No
Don't know
Have you had sex, or are you currently having sex, with a person who is HIV positive?
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Yes
No
Don't know
Are you, or any of your sexual partners, pregnant?
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Yes
No
Don't know
Are you, or any of your sexual partners within the last 12 months, between the ages of 15 and 24?
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Yes
No
Don't know
Have you had an HIV test before?
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Yes
No
What is the approximate date of your last HIV test?
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Month
-
Day
Year
Date
Do you know what PrEP (Pre-Exposure Prophylaxis) is?
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Yes
No
PrEP is a once daily medication that has been shown to be up to 99% effective at preventing an HIV infection when used consistently. At your appointment, would you like more information on PrEP's effectiveness, side effects, and cost, or a referral to a provider who can prescribe PrEP?
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Yes
No
Are you currently taking PrEP?
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Yes
No
At your appointment, would you like more information on PrEP's effectiveness, side effects, and cost, or a referral to a provider who can prescribe PrEP?
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Yes
No
Have you taken PrEP anytime in the last 12 months?
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Yes
No
May we leave a message on your voicemail, send a text or email with personal health information?
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Yes
No
Would you like to talk with someone about any questions or concerns related to your sexual health?
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Yes
No
Below are some ideas of topics we can discuss. Select (or write in) what you would like to address.
HIV/STI transmission routes
Prevention methods (condoms, communication, testing, PrEP, etc)
Communication with partners (condom negotiation, testing and sexual history, etc)
How to have safer sex while under the influence of drugs and alcohol
Is it safe to have sex with someone who is HIV+
Consent
Other
Would you like any condoms? All are free.
Traditional Latex
XL Latex
Latex Free
Dental Dams
At the time of your appointment, would you like help deciding which test may be best for you?
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Yes (I would like help deciding which tests to get)
No (I know what tests I'd like)
At the time of your appointment, would you like information about participating in a research study aimed at improving STI testing? Compensation is included. *Please Note* This study is for participants who were assigned male at birth (i.e. Cis-Men, Trans-Women, or other penis-having individuals).
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Yes
No
Please select which test(s) you'd like:
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Rapid HIV Test (Free)
Chlamydia & Gonorrhea Urine Test ($25)
Chlamydia & Gonorrhea Rectal Swab ($25)
Chlamydia & Gonorrhea Oral Swab ($25)
Syphilis ($15)
Have you been diagnosed with syphilis in the past?
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Yes
No
What is the approximate date you were diagnosed?
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-
Month
-
Day
Year
Date
Where were you diagnosed? Please list city and state, as well as the specific clinic if you know it.
If you would like your results sent to your provider, please provide as much contact information as you can:
Please select a date and time for your testing appointment. *IMPORTANT UPDATE* Test Site is taking place at UAF's new location: 150 S 1000 E, Suite 200, SLC UT 84102. Please note that Test Site is closed Monday, May 22nd, and Monday, May 29th. Questions? Email bobbi.farnsworth@utahaids.org.
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How did you hear about testing at UAF?
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I've been here before
Friends
Google/Internet
Social Media
Grinder and/or Scruff
Sex Party Outreach
Other outreach event
What can we do to improve?
By signing your legal name below, you state that you understand the testing procedures and give consent to all testing. You also certify that you are a current resident of Utah.
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