SEXUAL HEALTH SCREEN REGISTRATION

Pack Number

* required

First Name

* required

Surname

* required

Date of Birth

* required

Address

Post Code

* required

Telephone

Mobile

EMAIL

* required

Preferred contact method

SEXUAL HISTORY

What sex are you?

What sex is your partner?

When was the last time you had sex?

* required

How many partners have you had in the last 3 months?

* required

How many partners have you had in the last 12 months?

* required

Are condoms used?

MEN ONLY

Have you ever paid for sex?

Have you had sex with men?

Have you had a partner from a high risk country?

Have you had a blood transfusion or surgery or dentistry in a high risk country?

Have you injected drugs?

If you have had sex with men are you

WOMEN ONLY

Have you ever paid for sex?

Have you had a partner who has had sex with men?

Have you had a partner from a high risk country?

Have you had a blood transfusion or surgery or dentistry in a high risk country?

Have you injected drugs?

MEN AND WOMEN

Have you had VAGINAL sex?

Have you had ORAL sex?

Have you had ANAL sex?

HIV TESTING REQUIRES INFORMED CONSENT!

Have you received pre-test counselling and included in this discussion the reason why the test is being undertaken and the confirmatory procedure to be undertaken if required. Accordingly, have you given permission for a sample of blood to be taken, with due confidentiality, to a duly authorised Laboratory for HIV testing, the result to be forwarded directly, in confidence, to the requesting clinician and subsequently yourself. Should the result prove to be positive do you confirm the requirement for the need to arrange for the necessary counselling to be carried out.