Assessment Please Indicate your sex Male Female Other Please Select Your Age 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 Please select your ethnicity Black White Indian Coloured Other What is your highest level of education Primary School High School Diploma or Certificate Tertiary No Formal Education Do you have to travel away from home for long periods of time for work or other reasons? I do not regularly travel away from home Travel away from home for 1 week per month Travel away from home for 2 weeks per month Travel away from home for 3 weeks per month Travel away from home for a month or longer Which of the following sexual activities have you performed in last 6 months? Anal Receptive (You receive your partner’s penis in your anus) Anal Insertive (You insert your penis into your partner’s anus) Vaginal Receptive (You receive your partner’s penis in your vagina) Vaginal Insertive (You insert your penis into your partner’s vagina) Oral Receptive (You place your mouth on your partner’s vagina or penis) Oral Insertive (You place your vagina or penis in your partner’s mouth) None of the above Have you been assaulted in last 6 months? Yes - sexual assault Yes - physical assault No When was the last time you had an HIV test? 0-3 months 3-12 months More than 12 months Never had a test before Have you experienced/noticed any of the following Recent weight loss - more than 5kg over 3 months Blood in your cough in the last year A wet cough for more than 3 weeks in last 1 year Recurring night sweats in last few months Persistent fever or chills in last 1 year Persistent shortness of breath or chest pains in last 1 year Lived with someone who has had TB in the last year Diagnosed with or treated for TB in the last 2 years None of the above Have you experienced/noticed any of the following? White patches in your mouth Bad breath A sore throat Mouth ulcers A dry cough Do you use a condom during sex? Yes No Sometimes I haven’t had sex before Have you at anytime suffered from a sexually transmitted disease? Genital warts (small bump(s) on the genital(s) Genital ulcers (open sores on or around the penis or vagina. These can be painful or painless) Genital discharge (abnormal white or yellow liquid coming from the penis or vagina) Please select the number of male and female sexual partners you have had sex in the past 3 months If you are human, leave this field blank. Submit
