AIDS ALABAMA SOUTH

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SHELL HEALTH

HIV & STI
Testing
Registration

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Complete the form below to register for HIV & STI Testing at AIDS Alabama South.

First Name

Last Name

Reason For Visit

Sex Assigned at Birth

Personal Pronouns:

Gender Identity (Choose all that apply)

Man

Woman

Transgender

Trans Man

Trans Woman

Non-Binary

Answer Below:

Gender Identity

SSN

ID

Session Topic

Session Type:

Session Leader

ASO Code:

Select a date

Session Code

Today's Results

Test Type

Email

Phone

Birthday

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Housing Status:

HOMELESS

UNKNOWN

UNSTABLY HOUSED

STABLY HOUSED

AT RISK OF BEING HOMELESS

DECLINED

Have you had a previous HIV test with AIDS Alabama South?

Yes

No

Date of last HIV Test

Result of Test

Have you been tested for STIs/STDs in the last 24 months?

Yes

No

Unknown

If yes, which ones

Chlamydia

Herpes

Syphilis

Hepatitis

Gonarrhea

Trichomoniasis

Unsure

HPV

Have you been treated for STIs/STDs in the last 24 months?

Yes

No

Unknown

If yes, which ones

Chlamydia

Herpes

Syphilis

Hepatitis

Gonarrhea

Trichomoniasis

Unsure

HPV

On a scale of 1 - 10 (with 10 being always, and 1 being never), how often do you use condoms?

1

2

3

4

5

6

7

8

9

10

When was your last CONDOMLESS sexual encounter? (Approximate date is ok)

What type(s) of protection do you use against HIV, STIs, and Pregnancy during sex

In the last 12 months, have you had VAGINAL sex?

Yes

No

Unsure

In the last 12 months, have you had ANAL sex?

Yes

No

Unsure

In the last 12 months, have you had ORAL sex?

Yes

No

Unsure

In the last 12 months, have you had sex with a MALE?

Yes

No

Unsure

In the last 12 months, have you had sex with a FEMALE?

Yes

No

Unsure

In the last 12 months, have you had with someone who is TRANSGENDER?

Yes

No

Unsure

In the last 12 months, have you had sex with MULTIPLE PARTNERS?

Yes

No

Unsure

In the last 12 months, have you had MAN who has sex with MEN?

Yes

No

Unsure

In the last 12 months, have you had sex with someone who is living with HIV?

Yes

No

Unsure

In the last 12 months, have you had sex with someone who uses INJECTION DRUGS?

Yes

No

Unsure

In the last 12 months, have you had sex with someone who had an STI?

Yes

No

Unsure

In the last 12 months, have you had sex with someone while INTOXICATED OR HIGH?

Yes

No

Unsure

In the last 12 months, have you had sex with someone who has HEMOPHILIA, or has had a TRANSFUSION or TRANSPLANT?

Yes

No

Unsure

In the last 12 months, have you had sex with someone IN EXCHANGE FOR drugs, money or something you need?

Yes

No

Unsure

In the last 12 months, have you had sex with SOMEONE WHO EXCHANGES sex for for drugs, money, or something they need?

Yes

No

Unsure

In the last 12 months, have you had sex with someone of UNKNOWN RISK?

Yes

No

Unsure

By signing below, I acknowledge that I provide informed consent to receive the OraQuik, Insti, or Alere HIV Test, which checks for HIV antibodies. I understand this test is voluntary and confidential, but on the basis of a confirmed positive test result, AIDS Alabama South's obligation to the Alabama Department of Public Health warrants reporting of my information. I understand that this test is voluntary and I provide informed consent to receive a test which checks for HIV antibodies.

Your Signature

Thanks for submitting!

Clinic Hours

Monday: 9am to 4pm

Tuesday:11pm to 7pm

Wednesday: 9am to 4pm

Thursday: 9am to 4pm

Friday: 9am to 4pm

4321 Downtowner Loop N,

Mobile, AL 36609

251-289-0638

chance@shellhealth.org

© 2021 by AIDS Alabama South