HIV/STD AT-RISK QUESTIONNAIRE

The questionnaire contains sensitive questions and is not advisable for
persons under 13 years of age.

Please answer the following questions “yes” or “no” to determine your at-risk status for HIV/STD.

1. I am currently in a relationship in which neither my partner nor I have been tested for HIV/STD.
2. I have had “sex” without using a condom.
3. I have had oral sex without using a condom or latex barrier.
4. I have had sexual contact with someone who has had sex with someone other than me.
5. I have had sex with a man who has had sex with another man.
6. I have had a blood transfusion between 1977-1985 and have not been tested for HIV.
7. I have tested positive for a STD (including Hepatitis) and have never been tested for HIV.
8. I have had sex with someone who has had a blood transfusion between 1977-1985 or has tested positive for a STD (including Hepatitis) and have not been tested for HIV.

If you have answered “yes” to any of these questions, you may be at risk for HIV/STD’s.

Please call (816) 271-4725 for an appointment for free, confidential testing and risk reduction information. Thank you.