Registration Form
Fill out the form carefully for registration
Have you requested an Self Test Kit before?
*
Yes
No
Date
*
-
Month
-
Day
Year
Date
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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31
Day
Please select a year
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
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1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Year
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race
*
Gender Identity
*
Mobile Number
*
Sexual Orientation
*
E-mail
example@example.com
General Information
Date of last sexual exposure:
*
-
Month
-
Day
Year
Date
*
With Condom
Without Condom
Currently on PrEP or have taken PrEP?
*
Yes
No
I don't know
Type of Sex:
*
Oral
Vaginal
Anal(receptive)
Anal(insertive)
Number of partners in the past 2 months:
*
Number of partners in the past 12 months:
*
Known STIs:
*
Syphilis
Gonorrhea
Chlamydia
HIV
None
Risk Factors
Risk Factors
*
Baby Boomer
Close Contact (type: sex, household other)
Homelessness
Multiple Sex Partners
Men who Have Sex with Men
Occupational blood exposure
Piercings
Sharing Needles / Works
Tattoos
Unwanted Sexual Experiences
You or partners in jail/prison
Blood Products prior to 1992
Dialysis
Needle Stick
Organ Transplant
Prostitution
Sex with a person who has HIV/AIDS
Surgery / Dental
Travel (US or outside US)
No Risk
In the past 30 days have you had unprotected sex with a(n):
*
Male
Female
Transgender
Multiple partners
Men who have sex with men
HIV positive person
Exchange for drugs
Person who injected drugs
Client reports no known sexual risk factors
Risks in the past 12 months:
MSM
Illicit drug use
Female sex with an MSM
Multiple sex partners
Sex for money/drugs or Commercial sex
History of STD(s)
Testing History
Have you had an HIV test previously?
*
Yes
No
Don't Know
Year Last Tested:
*
-
Month
-
Day
Year
Date
Result
Negative
Positive
Don't Know
Would you like a test for any of the following STI's (Check all that applies)
Chlamydia
Gonorrhea
Trichomoniasis
Syphillis
Hepatitis C
Risk Behaviors (Sex) (Past 5 Years)
Vaginal or Anal Sex with a Male:
*
Yes
No
DON'TKNOW
Vaginal or Anal Sex with a Female:
*
Yes
No
DON'TKNOW
Vaginal or Anal Sex with a Transgender Person:
*
Yes
No
DON'TKNOW
PrEP & PEP Screening
Have you ever heard of PrEP (Pre-Exposure Prophylaxis)?
*
Yes
No
Are you currently taking daily PrEP medication?
*
Yes
No
Have you used PrEP anytime in the last 12 months?
*
Yes
No
Are you discontinuing PrEP today?
*
Yes
No
Have you had any exposure to HIV in the past 72 hours?
*
Yes
No
Consent for HIV Testing
Signature
*
Submit
Should be Empty: