In Person Home HIV Testing Form

HIV Testing Form

Please be sure to complete this very short form to receive your HIV test.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County (NOT Country)*
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Ethnicity*

Hispanic/LatinoNon Hispanic/Latino
Race*

American Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteNot SpecifiedDeclined to Answer
Assigned Sex at Birth*

MaleFemale
Current Gender/Identity*

MaleFemaleTransgender (male to female)Transgender (female to male)Transgender (unspecified)Another GenderDeclined to Answer
Have you ever heard of PrEP (Pre-Exposure Prophylaxis)?*

YesNo
Are you currently taking daily PrEP medication?*

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

YesNo
In the past 5 years, have you had sex with a MALE?*

YesNo
In the past 5 years, have you had sex with a FEMALE?*

YesNo
In the past 5 years, have you had sex with a transgender person?*

YesNo
In the past 5 years, have you injected drugs or substances?*

YesNo
Have you ever had an HIV test done previously?*

YesNo
Do you feel you need assistance in obtaining health benefits?*

YesNo
Do you believe your sexual behavior causes you to be more likely to be exposed to sexually transmitted diseases like HIV, HEP C, syphilis, gonorrhea, etc?*

YesNo
Do you feel you need any assistance with behavioral health services such as therapy?*

YesNo
Thank you for completing this form. The information within it is confidential. This is the first step to the HIV testing process. Once you submit this form, you will receive your HIV test. Do you understand this process?*

YesNo
This is a preliminary test. If you receive preliminary positive results, we will work with the Arkansas Department of Health and health care providers to get you an appointment to confirm the results. It is essential you share with us your results. Do you understand the information that has been shared?*

YesNo
Please enter any additional information you would like to share with Future Builders, Inc. Anything at all.*

YesNo
We have two office locations. Which are you closest to?

Pulaski County, Wrightsville, ARJefferson County, Pine Bluff, AR
Signature
Test Administrator USE ONLY

Test administrator to complete and submit form.
Test Administrator Name

First NameLast Name
Date

MonthDayYear
Date
County of Test Administration
Event or Location of Test Administration
Should be Empty:

HIV Testing Form

Test Administrator USE ONLY