CAQ English

Please complete the following client assessment questionnaire. The information provided is voluntary and will be kept confidential; it helps the CHIP HIV testing counselor to provide you with individualized risk-reduction advice.

Preferred Name *

* Indicates required field

Phone Number *

Social Media Handle or Email *

Please make sure your contact details are correct so we can reach out to you to arrange delivery of the test. If you do not hear from us within 2 business days, please get in touch via phone/email/social media.

What was your biological sex at birth? *

Male Female Intersex Prefer not to say

If Other please specify: *

What is your date of birth? *

What is the first letter of your last name? *

What County do you live in? *

What State do you live in? *

What is your zipcode? *

If Other, please specify: *

What is your current housing status? *

Homeless Unstably housed (at-risk of losing housing) Stably housed

What has been your most severe housing status in the past 12 months? *

Homeless Unstably housed (at-risk of losing housing) Stably housed

Which of the following comes closest to your sexual orientation? *

If Other, please specify: *

The following questions are about having sex with a MALE:

Have you had sex with a male in the past 12 months? (penis in vagina or penis in anus [butt]) *

Yes No

If Yes, what type of sex have you had with a male? *

Vaginal sex (penis in vagina) Anal insertive sex (your penis in your partner's anus [butt]) Anal receptive sex (your partner's penis in your anus [butt]) Without using a condom With someone who injects drugs With someone who you know has HIV or AIDS With someone who you know has had sex with another male (if your gender is female)

Have you had oral sex with a male in the past 12 months? *

Yes No

The following questions are about having sex with a FEMALE:

have you had sex with a female in the past 12 months? (penis in vagina or penis in anus [butt]) *

Yes No

If Yes, what type of sex have you had with a female? *

have you had oral sex with a female in the past 12 months? *

Yes No

The following questions are about having sex with a TRANSGENDER PERSON:

have you had sex with a transgender person in the past 12 months? (penis in vagina or penis in anus [butt]) *

Yes No

If Yes, what type of sex have you had with a transgender person? *

have you had oral sex with a transgender person in the past 12 months? *

Yes No

How many people have you had vaginal or anal sex with in the past 12 months? *

Have you used a needle to inject drugs in the past 12 months? *

Yes No

Have you received drugs, money, or other items or services for sex in the past 12 months? *

Yes No

If you have injected, did you share needles or drug injection equipment? *

Yes No

Have you had sex with a person who has exchanged sex for drugs or money in the past 12 months? *

Yes No

Have you EVER used a needle to inject drugs? *

Yes No

How many alcoholic drinks do you have on a typical day when you are drinking? *

Has a medical or service provider ever told you that you have hepatitis C? *

Yes No

Have you been diagnosed with any of the following in the past 12 months? *

Chlamydia Gonorrhea Syphilis I have NOT been told I have any of these

Have you used any of these drugs in the past 12 months? *

Stimulants (meth, speed, crank, crystal, cocaine, crack) Heroin Prescription opioids (Oxycontin, Percocet, Morphine, Methadone, Codeine, Fentanyl, Buprenorphine, Norco, Vicodin) Poppers (amyl nitrate) I have NOT used any of these drugs

Is there anything else that may have put you at risk for HIV? *

Yes No

If yes, please specify: *

Submit

Knowing your status is sexy. Stay sexy, stay safe, get tested!

Follow us on social media to keep up-to-date on all of our events and mobile testing schedule

Telephone:
1-888-581-CHIP (2447)

Email:
chip.syhc@gmail.com

This website may contain messages and/or material that may be unsuitable for some audiences. Since HIV infection is spread primarily through sexual behavior or by sharing needles, content on this site may address these topics. This site may also contain content from third party sources and links to other sites. San Ysidro Health Center, Inc. and CHIP are not responsible for such content.

Please complete the following client assessment questionnaire. The information provided is voluntary and will be kept confidential; it helps the CHIP HIV testing counselor to provide you with individualized risk-reduction advice.

Knowing your status is sexy. Stay sexy, stay safe, get tested!Follow us on social media to keep up-to-date on all of our events and mobile testing schedule

Knowing your status is sexy. Stay sexy, stay safe, get tested!

Follow us on social media to keep up-to-date on all of our events and mobile testing schedule