HIV Health Risk Assestment

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone

Please enter a valid phone number.

5

Sex Assigned at Birth?* This field is required.Risk may be elevated in individuals assigned male at birth due to MSM (men who have sex with men) exposure patterns.

Male

Female

Intersex

Perfer Not to Say

6

Race | Ethnicity* This field is required.Certain racial and ethnic groups are disproportionately affected by HIV due to structural and social determinants.

Black or African American

Hispanic or Latino/a/x

White

Asian

Native American or Alaska Native

Native Hawaiian or Pacific Islander

Other / Prefer not to say

7

Have you had multiple sexual partners in the last 6 months?

YESNO

8

Do you consistently use condoms during sex?

YESNO

9

Have you ever injected substances or medications outside of a medical setting?

YESNO

10

Have you ever shared needles or injection equipment with someone else?

YESNO

11

Have you ever been tested for HIV?Recent testing is a protective behavior and indicates health engagement.

Never Tested

Tested more than 12 months ago

Tested in the past 12 months

12

Total Score

13

HIV Severity

14

Please verify that you are human* This field is required.