Follow-up questionnaire - Clinique l'Actuel

PrEP QUESTIONNAIRE
Follow-up visit

Your answers to the following questions will be treated confidentially by our medical team. Your responses help us better understand your situation and expectations so we can provide treatments and services tailored to your needs.

You must answer each question before submitting the questionnaire.

Date

Last name

First name

File numbers

Date of birth

How many medical consultations did you have before deciding to start PrEP?

What type of PrEP are you currently taking?

What medication do you take for PrEP?

Since your last visit, have you missed any doses?

Have you experienced any side effects since starting PrEP?

Headaches

Fever

Nausea

Diarrhea

Stomach cramps

Fatigue

Vertigo (dizziness)

Other

In the past three months, have you been diagnosed with any of the following infections?

Chlamydia

Gonorrhea

Hepatitis (A or B)

Hepatitis C

Herpes

Mpox (simian smallpox)

Syphilis

HPV / General warts

Other

In the past three months :

Have you had a primary sexual partner?

How many sexual partners have you had?

How often do you consume alcohol?

In the past three months, has your drug use:

In the past three months, has your alcohol consumption:

In the past three months, have you used any of the following substances?

Cannabis

Cocaine

Crack

Crystal meth

GHB

Heroin

Ketamine

MDMA (ecstasy)

Opioids (e.g. fentanyl)

Poppers

In the last three months, have you:

Had sex with someone who is HIV-positive?

Had sex with someone whose HIV status you did not know?

Had sex with a sex worker?

Worked as a sex worker?

Received post-exposure treatment to prevent HIV following a risky activity?

Used apps to meet partners (e.g. Grindr)?

Visited a sauna?

In the past three months :

How often did you use condoms during sex?

Have you had anal sex?

Have you had vaginal (frontal) sex?

Have you had oral sex?

Do you have private insurance for medications?

PrEP QUESTIONNAIRE
Follow-up visit

Clinic opening hours

Telephone reception hours

PrEP QUESTIONNAIRE Follow-up visit

PrEP QUESTIONNAIRE
Follow-up visit