HIV Testing Registration & Scheduling Form
Please complete the following questions to the best of your ability. All information you provide will be completely confidential.
Legal Full Name
*
MI
Preferred Name
Optional
Name on email
Date of Birth
*
/
Month
/
Day
Year
Email
*
example@example.com
Contact Information:
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Is this a shared phone?
Yes
No
Other
May we leave a message?
Yes
No
Other
For your privacy, what if anything, may we mention? (Check all that apply)
Quest Center for Integrative Health
HIV testing
Other
How did you hear about us?
Quest Client/Provider
Other Healthcare Provider
Social Service Provider
Insurance Company
Ad/Brochure
Quest Website
Social Media/Facebook
Other
Appointment information:
All testing is done in person, at our clinic location at 2901 E Burnside St, Portland OR 97209. Masks are worn and required at all times. Masks will be available at our front desk if requested.
Appointment with Available Tester
*
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Demographics:
Your optional responses help Quest develop culturally responsive and inclusive programs. As a Non-Profit, we collect this data in order to secure funding for marginalized populations, but understand that one’s identity can’t be reduced to a series of boxes.
Gender Identity:
Female
Genderqueer/Non-Binary
Male
Other
Sex at birth:
Female
Male
Intersex
Pronouns:
She/Hers
He/Him
They/Them
Other
Do you identify as transgender?
Yes
No
Other
Do you think of yourself as:
Lesbian/Gay
Straight/Hetero
Bi/Pan-sexual
Queer
Asexual
Other
What are the genders of the people you have sex with? Do any of them identify as transgender?
Female
Male
Non-binary/Genderqueer
Trans (MTF)
Trans (FTM)
Trans (Unspecified)
Other
Housing Status:
Permanent
Temporary
Houseless
Other
Please choose all options that best describe your racial or ethnic heritage:
Black/African American
White/European
Middle Eastern/North African
Asian
Native/Indian/Indigenous American
Alaska Native/Eskimo
Widowed
Native Hawaiian/Pacific Islander
Hispanic
Latin American/Latinx/Caribbean
Mexican/Chicanx/Xicanx
Other
Past HIV testing:
Please complete the following questions to the best of your ability. All information you provide will be completely confidential. These questions help us understand which populations are accessing testing, and who we may not be reaching. We know that certain groups are at higher risk for HIV, but we also know that risk comes in many different shapes and sizes, and that the virus doesn’t discriminate.
Have you been tested for HIV before?
*
Yes
No
Other
What was the estimated date of your last test?
Month/Year
What was the result?
Negative
Positive
Don't know
Preliminary positive (Clinic)
Preliminary positive (Home)
Other
What made you decide to come in today?
What had kept you from testing in the past?
Risk for HIV:
Please complete the following questions to the best of your ability. All information you provide will be completely confidential. These questions help us understand what resources and information we can provide to you, to help reduce your risk of contracting HIV.
In the past 12 months, have you:
Had anal or vaginal sex?
Exchange sex for drugs, money, or something you needed?
Had receptive sex with a person who also has receptive sex with others?
Had vaginal or anal sex with a person who is living with HIV?
Had vaginal or anal sex with a person who injects drugs?
Used injection drugs?
Did you use condoms?
Yes, all the time
Most of the time
Sometimes
No
Other
Have you shared injection equipment within the past 12 months?
Yes
No
Other
Have you had vaginal or anal sex with a person who is living with HIV but not undetectable?
Yes
No
Other
Undetectable = Untransmittable
People living with HIV who achieve and maintain an undetectable viral load—the amount of HIV in the blood—by taking antiretroviral therapy (ART) daily as prescribed cannot sexually transmit the virus to others. (niaid.nih.gov/diseases-conditions/treatment-prevention - 2019)
Is there any concern that you might have contracted HIV within the past 7 hours, whether from sex or needle sharing?
*
Yes
No
Other
Is there any chance you could be pregnant?
Yes
No
Other
Are you taking PrEP?
Yes
No
Other
Would you like information on how to access:
Needle exchange/ Safe injection information
STI testing
PrEP (Pre-Exposure Prophylaxis, a once daily tablet to reduce the risk of HIV)
Other
I consent to rapid HIV Testing and confirmatory testing, should there be a reactive result.
I consent to having information regarding any reactive results being shared with County DIS and the State Public Health Department for the purpose of early engagement in care. My signature acknowledges my understanding that a reactive HIV result is reportable to local and state public health entities.
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