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Have you ever been tested for:
 
Gonorrhea
 
Chlamydia
 
Syphillis
 
Genital Herpes
 
Hepatitis B or C
 
HIV/AIDS
 
HPVs or Genital Warts

 
 
 
Gender:
 
Male
 
Female
 
 
 
Age:
 
Under 18 years old
 
18-24 years old
 
25-34 years old
 
35-44 years old
 
Over 44 years old
 
 
 
Is HIV/AIDS a concern in your community?
 
Yes
 
No
 
 
 
Would you get tested if you were offered:
 
Free test
 
Free at home test
 
Free entry to night club/social
 
Free concert event
 
Restaurant Certificate

 
 
 
Please specify your race:
 
American Indian or Alaska Native
 
Asian
 
Black or African Descent
 
Hispanic or Latino
 
Native Hawaiian or other Pacific Islander
 
White or Caucasian

 
 
 
Marital Status:
 
Never Married
 
Married
 
Widowed
 
Divorced
 
Separated
 
 
 
What is the level of school you have completed?
 
GED or equivalent
 
High School graduate
 
Some College
 
Associate Degree
 
Bachelor's Degree
 
Graduate School
 
Professional Degree
 
 
 
Do you own or rent your home?
 
Rent
 
Own
 
 
 
Are you currently:
 
A student
 
Employed
 
Military
 
Self Employed
 
Retired
 
A homemaker
 
Unemployed
 
Unable to work