PrEP Her – The Normal Anomaly Initiative, Inc.

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PrEPHer Panel Testing

Fill this form out to receive a free self-testing kit which screens for: CHLAMYDIA GONORRHEA HEPATITIS C (Hep C) HIV (I and II) HERPES SIMPLEX 2 SYPHILIS TRICHOMONIASIS (Trich) Our center responds within 24-48 hours. Monday- Friday

Date(Required)

MM slash DD slash YYYY

Name(Required)

First (chosen/preferred) Last

Date of Birth(Required)

Month

Day

Year

Valid Phone #(Required)

Valid Email(Required)

Valid Address(Required)

Street Address Address Line 2 City State ZIP Code

What is your gender identity?(Required)

Cisgender Female (assigned female at birth)

Trans Male

Trans Female

Intersex

Gender Nonconforming/Non-binary

Other

What is your sexual orientation?(Required)

Heterosexual

Gay

Bisexual

Same Gender Loving

Queer

Asexual

Other

What is your race/ethinicity?(Required)

Black / African American

Hispanic / Latinx

Native American / Indigenous

Hawaiian / Pacific Islander

White

Asian

Other

How did you hear about this testing program?(Required)

PrEPHer Ambassador

Facebook: The Normal Anomaly

Instagram: @thenormalanomaly

Website: normalanomaly.org

Friend/Family

Community Based Organization

Walk-in

Check all that apply.

How often do you get tested?(Required)

4 times a year

3 times a year

2 times a year

once a year

less than once a year

Do you know your HIV status?(Required)

Yes, HIV positive

Yes, HIV negative

No, unsure

Never been tested for HIV before

Prefer not to disclose

Are you familiar with PrEP?(Required)

Yes, I am currently taking PrEP

Yes, but not currently taking PrEP

No, have little information on PrEP

No, never heard of PrEP

Employment status(Required)

Employed full-time

Not employed

Student

Self employed

Employed part-time

Other

Living situation (where have you slept most nights in the past 3 months)(Required)

Home or Apartment (rent/own)

Homeless shelter/ Transitional housing/ Halfway house

Jail/Nursing home/Recovery center

Outside/ On the streets

Prefer not say

Other

Check all that apply.

Living situation: Other

Anti-SPAM: What is 6 + 4?(Required)

Comments

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The Normal Anomaly Initiative, Inc.
2310 Arbor Street,
Houston, Texas 77004

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