At Home Intake Form

Legal Name *

First Name Last Name

Preferred Name

Pronouns

Date of Birth *

Date

Phone Number *

Area Code Phone Number

Email

example@example.com

Email Address *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Do you have insurance? / ¿Usted tiene seguro? *

Yes/Si No

Ethnicity/Grupo ètnico *

Hispanic/Hispano, Latino Not Hispanic/No Hispano, Latino Don’t Know/ No Sè

Race/Raza: *

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 *

Male/Varon Female/Hembra Prefer not to answer

Gender/Género *

Man/Hombre Woman/Mujer Non-Binary/No binario(a)

Are you Intersex?

Yes No

Do you have sex with (Check all that apply) /¿Usted tiene relaciones sexuales con: *

Men/Hombres Women/Mujeres Transgender and Non-binary people

What types of sexual encounters do you have (Check all that apply) *

Vaginal Receiving Vaginal Giving Vaginal Both Anal Receiving Anal Giving Anal Both Oral Receiving Oral Giving Oral Both

In the past 12 months have you or any of your sexual partners injected drugs? *

Yes No

Would you like any harm reduction supplies? Syringes, cookers, sharps containers, etc. These are free. *

Yes No

In the past 12 months have you bought, sold, or traded sexual services either for money or for something you have needed? *

Yes No

Would you like to talk with someone on how to reduce your risks for HIV/STIs while buying, selling, or trading for sexual services? *

Yes No

Have any of your sexual partners from the past 4 weeks tested positive for Chlamydia, Gonorrhea, or Syphilis? *

Yes No Don't Know

Are you, or any of your current sexual partners, pregnant? *

Yes No Don't Know

Are you, or any of your sexual partners within the last year, between the ages of 15 and 24? *

Yes No Don't Know

Have you had an HIV test before? *

Yes No

Approximate date of your last HIV test

Date

Do you know what PrEP (Pre-Exposure Prophylaxis) is? *

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. Would you like more information regarding PrEP? *

Yes No

Are you currently taking PrEP? *

Yes No

Would you like information on how to get on PrEP? *

Yes No

Have you taken PrEP anytime in the last 12 months? *

Yes No

May we leave a message on your voicemail, send a text or email with personal health information? / Podemos dejar un mensaje en el buzón de voz con la información personal de salud ? *

Yes No

Preferred method of communication.

Email Call Either

Do you have any questions or concerns related to your sexual health that you would like to talk with someone about?

Yes No

Is there anything specific you would like to talk about?

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 is safe to have sex with someone who is HIV+? Consent

UAF is partnering with Northwestern University to provide online sexual health education tailored to young gay and bisexual men. By participating, some individuals may qualify to receive free HIV/STI testing for the next year. Would you be interested in hearing more about the program? *

Yes No

We will call you later in the evening, so expect a call from an unknown number.

Would you like any condoms? All types are free.

Regular latex condoms XL latex condoms Latex free condoms Internal condoms

What test(s) would you like? All testing is free in June. Happy Pride month! *

Rapid HIV Test Syphilis Chlamydia & Gonorrhea Oral Swab Chlamydia & Gonorrhea Rectal Swab Chlamydia & Gonorrhea Urine

Have you been diagnosed with syphilis in the past? *

Yes No

What is the approximate date you were diagnosed? *

Date

Where were you diagnosed? City and state. Specific clinic if you know it.

If you would like your results sent to your doctor please provide their name, office fax number, and office phone number

If you would like your results sent to your provider, please provide as much contact information as you can. A release of information will be sent to via email.

Would you like a copy of your STI test results emailed to you?

Yes No

Please select a time you would like to come in for testing. We will not be accepting walk-ins in an effort to limit the amount of people in the building at one time. You will only be allowed to test during the time that you are signed up for. You will receive a text reminder the day of your appointment. *

Do you prefer making appointments for testing at UAF, or do you prefer our pre-COVID walk-in system? *

Appointments Walk-In No Preference This is my first time testing at UAF

By signing your legal name below you state that you understand the testing procedure, and give consent to all the testing you have selected above. *

Clear

Utah AIDS Foundation At Home Testing Intake Form