Online Health Form – ENGLISH

ONLINE HEALTH SURVEY

* = Required

Client Identification

IMPORTANT:

Many data fields in this online form are optional. VIDA does not sell or share any personal identification information with outside third parties.

Your Email

If "Other":

County:

San Diego

Other

If "Other":

State:

Zip Code:

Current Housing Situation:

Currently Homeless

Unstable Housing

Stably Housing

Other

If "Other":

Client Demographics

Ethinicity (mark one):

(1) Hispanic or Latino

(2) NOT Hispanic or Latino

(8) Client doesn't know

(2) Declined to answer

Sex assigned at birth:

Male

Female

Declined to answer

If "not listed"

Are of Populations:

Rural

Suburban

Urban Cluster

Urban

Age Group

Grupo:

Adolescents/Youth (<18)

Young Adults (18-29)

Adults (30 – 64)

Older Adults (65+)

HIV and STI Testing History

HIV test before today?

(1) Yes (PROCEED TO NEXT SECTION IF "YES")

(0) No

(8) Client doesn't know

(9) Declined to answer

Most recent HIV result received (before today)

Client PrEP Awareness and Use

Ever heard of PrEP?

(1) Yes

(0) No

Currently taking daily PrEP neducatuin

(1) Yes

(0) No

Use PrEP anytime in the last 12 months

(1) Yes

(0) No

If not on PrEP, wants PrEP?

(1) Yes

(0) No

Currently taking PEP?

(1) Yes

(0) No

Needle and Syringe Sharing Behaviors of Populations Requesting HIV Tests

People with Lived Experiences of Alcohol and Substance Use Disorder:

(1) Yes

(0) No

In your lifetime, have you ever injected drugs that were not prescribed to you by a medical care provider?

(1) Yes

(0) No

Priority Populations

In the past 5 years, have you had vaginal or anal sex with the following partners (mark all that apply):

Male Partner

Declined

No

Yes

If "Yes" to Male Partner

With no condom

Who injects drugs

Who is HIV positive

Female Partner

Declined

No

Yes

If "Yes" to Female Partner

With no condom

Who injects drugs

Who is HIV positive

Transgender Partner

Declined

No

Yes

If "Yes" to Transgender Partner

With no condom

Who injects drugs

Who is HIV positive