Risk Assessment Form

What is your age?

What is your sex?

Male Female

What is your current county of residence?

Select an option Mombasa Kwale Kilifi Tana River Lamu Taita-Taveta Garissa Wajir Mandera Marsabit Isiolo Meru Tharaka-Nithi Embu Kitui Machakos Makueni Nyandarua Nyeri Kirinyaga Murang'a Kiambu Turkana West Pokot Samburu Trans Nzoia Uasin Gishu Elgeyo-Marakwet Nandi Baringo Laikipia Nakuru Narok Kajiado Kericho Bomet Kakamega Vihiga Bungoma Busia Siaya Kisumu Homabay Migori Kisii Nyamira Nairobi

What is your marital status?

Single Cohabiting Married Monogamous Married Polygamous Divorced Widowed

Is/was your partner HIV positive?

Yes No

In the past 12 months, have you had sex with a woman?

Yes No

In the past 12 months, have you had sex with a man?

Yes No

In the past 12 months, did you use condoms for vaginal or anal sex?

I always use condoms with all my partners I sometimes use condoms with all my partners I never use condoms with all my partners Not applicable as no vaginal or anal sex

Are you a sex worker?

Yes No

Do you regularly use needles to inject drugs?

Yes No

Have you been tested for HIV in the past 3 months?

Yes No

Have you experienced any one of these symptoms? (cough at any duration, fever, unintended weight loss, drenching night sweat)?

Yes No

Are you on TB treatment?

Yes No

Have you had STI (Sexually Transmitted Infections) in the past?

Yes No

Have you ever been a victim of rape?

Yes No

Are you currently using HIV Pre-exposure Prophylaxis (PrEP)?

Yes No

Submit