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Risk Assessment for Prevention

DOH Form 1628

These questions are required by the State of Florida's HIV Prevention program to receive free testing services.
This question requires a valid date format of MM/DD/YYYY.
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2. Personal Information
This question requires a valid email address.
This question requires a valid date format of MM/DD/YYYY.
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Ethnicity (Select One)
Race (Select one or more)
Self Reported Gender
Birth Sex
Pregnant?
If Pregnant, In prenatal care?
3. Previous HIV Test?
This question requires a valid date format of MM/DD/YYYY.
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5. Result of Last HIV Test
6. HIV Positive?
7. If YES, are you taking antiretroviral medication to treat HIV?
8. Hepatitis C Positive?
9. If YES, have you been treated for Hepatitis C?
10. Risk Factors

 
Space Cell
Vaginal or Anal Sex with
Without using a condom
With an Injection Drug User
With an HIV positive person
10. Have you...
Space Cell During the past 12 monthsDuring the past 5 years
had vaginal/anal sex with a Man who has sex with other men? (FEMALES Only)
hand an anonymous partner?
had sex for drugs, money or other items?
had an Sexually Transmitted Disease diagnosis?
used injection drugs?
If yes, did you share injection equipment?
been homeless or unstably housed?