Please complete the following HIV Testing Risk Assessment form.Testing Risk Assessment Date(Required) MM slash DD slash YYYY Name(Required) First (chosen/preferred) Last Date of Birth(Required) Month Day Year What is your age?(Required)Valid Phone #(Required)Valid Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you give permission for the testing team to contact via the number you provided?(Required) Yes No N/A What is your gender identity?(Required) Cisgender Male (assigned male at birth) Cisgender Female (assigned female at birth) Transgender Male Transgender Female Intersex Gender Nonconforming/Non-binary Other What is your sexual orientation?(Required) Heterosexual Gay Bisexual Same Gender Loving Queer Asexual Other What is your race/ethinicity?(Required) Black / African American Hispanic / Latinx Native American / Indigenous Hawaiian / Pacific Islander White Asian Other How did you hear about this testing program?(Required) Facebook: The Normal Anomaly Twitter: @danormalanomaly Instagram: @thenormalanomaly Website: normalanomaly.org Friend/Family Community Base Organization Walk-in Other Check all that apply.How did you hear about this testing program?: Other How often do you get tested?(Required) 4 times a year 3 times a year 2 times a year once a year less than once a year Do you know your HIV status?(Required) Yes, HIV positive Yes, HIV negative No, unsure Never been tested for HIV before Prefer not to disclose Did you receive the results of your last HIV test?(Required) Yes; result was negative Yes; result was positive Yes; result was preliminary positive/ indeterminate No Prefer not to say Don't know If you are HIV- positive, how long did you see a doctor for your HIV (CD4 Count, Viral Load and/or Medication)?(Required) In the past 6 months More than 3 months I have never seen a doctor for my HIV Prefer not to say Not applicable Don't know Employment status(Required) Employed full-time Not employed Student Self employed Employed part-time Other Living situation (where do you slept most nights in the past 3 months)(Required) Home or Apartment (rent/own) Homeless shelter/ Transitional housing/ Halfway house Jail/Nursing home/Recovery center Outside/ On the streets Prefer not say Other Check all that apply.Living situation: Other Are you familiar with PrEP?(Required) Yes, I am currently taking PrEP Yes, but not currently taking PrEP No, have little information on PrEP No, never heard of PrEP How many people has the client had any sexual contact with in the past 3 months (anal, oral, vagina etc.)?(Required) How many people has the client had any sexual contact with in the past 12 months (anal, oral, vagina etc.)?(Required) How many people has the client had unprotected sexual contact with in the past 12 months (anal, oral, vagina etc.)?(Required) Of these sexual encounters, how many were anonymous (someone you didn't know)?(Required) Had an STD (syphilis, gonorrhea, chlamydia, herpes, HPV) in the past...(Required) Syphilis Gonorrhea Chlamydia Herpes HPV Other STD: Other Been incarcerated (jail or prison) in the past...(Required) 6 months 12 months Don't know Prefer not to say Never Had sex in exchange for drugs/money/something you need in the past...(Required) 6 months 12 months Don't know Prefer not to say Never Injected drugs/substances (narcotics, hormones, silicone) in the past...(Required) 6 months 12 months Don't know Prefer not to say Never Met a sexual partner online or dating apps(Required) Yes No How many partner(s) have you had sex while intoxicated and/or high on drugs?Male (6 months)Male (12 months)Female (6 months)Female (12 months)Transgender (6 months)Transgender (12 months)Non-binary (6 months)Non-binary (12 months)How many partner(s) have you had sex with a person who injects drugs?Male (6 months)Male (12 months)Female (6 months)Female (12 months)Transgender (6 months)Transgender (12 months)Non-binary (6 months)Non-binary (12 months)How many partner(s) have you had sex with a person who has HIV?Male (6 months)Male (12 months)Female (6 months)Female (12 months)Transgender (6 months)Transgender (12 months)Non-binary (6 months)Non-binary (12 months)How many partner(s) have you had sex with a person who has unknown HIV status?Male (6 months)Male (12 months)Female (6 months)Female (12 months)Transgender (6 months)Transgender (12 months)Non-binary (6 months)Non-binary (12 months)How many partner(s) have you had sex with a person who has unknown HIV status?Male (6 months)Male (12 months)Female (6 months)Female (12 months)Transgender (6 months)Transgender (12 months)Non-binary (6 months)Non-binary (12 months)Where did you find out about the HIV testing service being offered today?(Required) Self-referred Partner/Spouse Friend/Family Religious Leader Doctor/Medical Facility Advertisement/Poster HIV/STD hotline Referred from other agency Internet Web Site TV/Radio station Don't know Other Anti-SPAM: What is 6 + 4?(Required) PhoneThis field is for validation purposes and should be left unchanged.
