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

If Other please specify: *

What is your date of birth? *

WHAT IS YOUR CURRENT AGE? *

What zip code do you live in? *

What County do you live in? *

What State do you live in? *

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

If Other, please specify: *

Have you been tested for HIV before today? *

Yes No I don't know

Have you heard about PrEP before? *

Yes No

Do you have health insurance? *

No Yes

Are you currently on PrEP? *

Yes No

Have you used PrEP anytime in the last 12 months? *

Yes No

If Yes, please specify: *

If not on PrEP, are you interested in PrEP? *

Yes No

In the past 5 years, have you had a MALE sex partner? *

Yes No

In the past five years, have you had a FEMALE sex partner? *

Yes No

If your gender is female, have you had a MALE sex partner who has had sex with another male? *

Yes No

in the past five years, have you had a trans or genderqueer/non-binary sex partner? *

Yes No

in the past 12 months, how many people have you had sex with? *

In the past 12 months, have you been diagnosed with any of the following? *

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

in the past 12 months, have you had sex without a condom? *

Yes No

in the past 5 years, have you injected drugs that were not prescribed to you by a medical care provider? *

Yes No

did you ever receive blood tissue before 1992? *

Yes No

have you ever injected drugs that were not prescribed to you by a medical care provider? *

Yes No

do you receive hemodialysis? *

Yes No

has a medical or service provider ever told you that you have Hepatitis C? *

Yes No

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

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