PrEP Recommendation Form

Sexual Activity in Last 6 Months

No

Yes

Please select an option.

Partner Gender

Male

Female

Both

Non-binary

Please select your partner's gender.

Multiple Partners?

Yes

No

Please select if you have multiple partners.

Type(s) of Sexual Activity

Anal

Vaginal

Oral

Please select at least one type of sexual activity.

Discussed HIV Status with Partner?

Yes

No

Please select if you discussed HIV status with your partner.

Know partner's HIV Status

I don't ask

Always

Sometimes

Please select your partner's HIV status.

Condom Use with Partner(s)

Always

Sometimes

Never

Please select condom use frequency.

STI Diagnosis in Last 6 Months

Never

Unsure

Yes

Please select if you had an STI diagnosis in the last 6 months.

Injected Drugs?

Never

Yes

Please select if you have injected drugs.

Attended Chemsex Parties?

Yes

No

Please select if you attended sex parties.

Exchanged Sex for Money/Drugs?

Yes

No

Prefer not to answer

Please select if you exchanged sex for money or drugs.

Additional Concerns or Comments (Optional)