Walk-In Intake

HIV/STI Test Site Intake Form

Formerly Utah AIDS Foundation
Legal Name*

First NameLast Name
Preferred Name
Pronouns
Date of Birth*

MonthDayYear
Date
Are you between the age of 18 and 34?*

YesNo
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have health insurance? / ¿Usted tiene seguro?*

Yes/SiNo
Ethnicity / Grupo ètnico:*

Hispanic/Hispano, LatinoNot Hispanic/No Hispano, LatinoDon't know/No Sè
Race/Raza:*

American Indian/Alaska Native – Indígena AmericanoAsian/Asian American - Asiático/Asiático AmericanoBlack/African American – Negro/AfroamericanoWhite/European American –Blanco/EuroamericanoHawaii Native/Pacific Islander – Nativo de Hawaii/Isl. Del PacDon’t Know/No Sé
Sex assigned at birth / Sexo:*

Male/VaronFemale/HembraPrefer not to answer
Gender / Género*

Man/HombreWoman/MujerNon-Binary/No binario (a)TransgenderOther
Who do you have sex with? / ¿Usted tiene relaciones sexuales con? Check all that apply.*

Men/HombresWomen/MujeresTransgender and Non-binary peopleOther
What types of sexual encounters do you have?*

Vaginal ReceivingVaginal GivingAnal ReceivingAnal GivingOral ReceivingOral Giving
In the past 12 months have you used injection drugs?*

YesNo
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.

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

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

YesNo
In the last 12 months, have you been a victim of sexual violence?*

YesNoMaybe/Don't know
Would you like to be connected with resources regarding your experience?

YesNo
In the past 12 months, have you or any of your sexual partners tested positive for Gonorrhea or Syphilis?*

YesNoDon't know
Have you had sex, or are you currently having sex, with a person who is HIV positive?*

YesNoDon't know
Are you, or any of your sexual partners, pregnant?*

YesNoDon't know
Are you, or any of your sexual partners within the last 12 months, between the ages of 15 and 24?*

YesNoDon't know
In the past 12 months, have you had sex without a condom?*

YesNo
In the past 12 months, have you had more than 1 sexual partner?*

YesNo
Have you had an HIV test before?*

YesNo
What is the approximate date of your last HIV test?

MonthDayYear
Date
What is your HIV status?*

PositiveNegativeDon't know
Do you know what PrEP (Pre-Exposure Prophylaxis) is?*

YesNo
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?*

YesNo
Are you currently taking PrEP?*

YesNo
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?*

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

YesNo
May we leave a message on your voicemail, send a text, or email with personal health information?*

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

YesNo
Below are some ideas of topics we can discuss. Select (or write in) what you would like to address.

HIV/STI transmission routesPrevention 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 alcoholIs it safe to have sex with someone who is HIV+ConsentOther
Would you like any condoms? All are free.

Traditional LatexXL LatexLatex FreeDental Dams
At the time of your appointment, would you like help deciding which tests may be best for you?*

Yes (I would like help deciding which tests to get)No (I know what tests I'd like)
Please select which test(s) you'd like:*

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?*

YesNo
What is the approximate date you were diagnosed?*

MonthDayYear
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 appointment. Questions? Email nico.lockhart-allen@uafhealth.org*
How did you hear about testing at UAF?*

I've been here beforeFriendsGoogle/InternetSocial MediaDating/Hookup appsOutreach event
What can we do to improve?
Please review UAFLH Notice of Privacy Practices:
Terms and Conditions*
Please review UAFLH Consent for Testing and Treatment Agreement:
Terms and Conditions*
I agree and understand that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.*

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HIV/STI Test Site Intake Form

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