Utah AIDS Foundation At Home Testing Intake Form
Legal Name
*
First Name
Last Name
Preferred Name
Preferred Prounouns
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
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:
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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
*
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)
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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?
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Yes
No
Don't Know
Are you, or any of your current sexual partners, pregnant?
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Yes
No
Don't Know
Are you, or any of your sexual partners within the last year, 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
Approximate date of your last HIV test
-
Month
-
Day
Year
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?
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Yes
No
Would you like information on how to get on 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? / Podemos dejar un mensaje en el buzón de voz con la información personal de salud ?
*
Yes
No
Preferred method of communication.
Email
Call
Either
Would you like to set up a phone call with someone to discuss any sexual health questions you may have?
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? We accept cash and card at time of checking in.
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Rapid HIV Test (Free)
Syphilis ($15)
Chlamydia & Gonorrhea Oral Swab ($25)
Chlamydia & Gonorrhea Rectal Swab ($25)
Chlamydia & Gonorrhea Urine ($25)
Have you been diagnosed with syphilis in the past?
*
Yes
No
What is the approximate date you were diagnosed?
*
-
Month
-
Day
Year
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?
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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
Submit
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