Other:2.If you have symptoms, please check all that apply:BleedingPainRashWartsItchingProblems with urination Other:3.Have you had sexual interactions with anyone in the last 6 months? YesNo With how manypeople?12345678910more than 104.How many people have you had sexual interactions with in your lifetime?012345101525305075more than 1005.When with new or non-steady partners, do you use a condom or barrier?AlwaysMost of the timeSometimesRarelyNever6.Have you had sexual interactions with:A manA womanBoth Other7.Check all that apply:Oral sexVaginal sexAnal sex: Top (Insertive)Bottom (Receptive)Both8.Please list any medication(s) you are currently taking:9.Please list any allergies to medication(s):10.Have you ever exchanged drugs or money for sex?YesNo11.Have you had sex with someone you know injects drugs?YesNo12.Have you ever used a needle to inject drugs?YesNo13.Have you had sexual interactions with someone you know has HIV/AIDS? YesNo14.Have you used meth, speed, crank, crystal, cocaine, or crack in the last year? YesNo15.Do you smoke cigarettes? YesNo16.Have you ever been in jail or prison? YesNo17.Do you have any tattoos? YesNoPage 18118.
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