At Home Intake

Legal Name *

First Name Last Name

Preferred Name

Pronouns

Date of Birth *

Date

Are you between the age of 18 and 34? *

Yes No

Phone Number *

Please enter a valid phone number.

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Do you have health 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) Transgender Other

Who do you have sex with? / ¿Usted tiene relaciones sexuales con? Check all that apply. *

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

What types of sexual encounters do you have? *

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

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

Yes No

Would you like any injection supplies? (Syringes, cookers, containers, etc.) All are free.

Yes No

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

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? *

Yes No Don't know

Have you had sex, or are you currently having sex, with a person who is HIV positive? *

Yes No Don't know

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

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? *

Yes No Don't know

Have you had an HIV test before? *

Yes No

What is the 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. 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? *

Yes No

Are you currently taking PrEP? *

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? *

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? *

Yes No

Would you like to talk with someone to address any questions or concerns related to your sexual health? *

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 to talk with someone to help determine which tests are most appropriate? *

Yes (I would like help determining which tests to get) No (I know what tests I'd like)

Please select which test(s) you'd like: *

Rapid HIV Test (Free) Syphilis ($15) Chlamydia & Gonorrhea Urine Test ($25) Chlamydia & Gonorrhea Oral Swab ($25) Chlamydia & Gonorrhea Rectal Swab ($25)

Have you been diagnosed with syphilis in the past? *

Yes No

What is the approximate date you were diagnosed? *

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 possible:

Please select a date and time for your testing appointment. Appointments help maintain a smooth flow so you can be seen sooner and get out faster. You will receive a reminder test the morning of your appointment: *

How did you hear about testing at UAF? *

I've been here before Friends Google/Internet Social Media Grinder and/or Scruff Other

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 state that in the past 14 days you have not experienced any symptoms of COVID-19 and that you are a current resident of Utah. *

Clear

Utah AIDS Foundation At-Home HIV Testing