Questionnaire - Clinique l'Actuel

PrEP QUESTIONNAIRE
Initial 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

What is your sex at birth?

What is your gender identity?

What is your sexual orientation?

What is your ethnic or cultural background?

What is your legal status in Canada?

What is the highest level of education you have completed?

What is your annual income (before taxes)?

Do you have private insurance for medications?

Have you ever been diagnosed with the following infections?

Chlamydia

Gonorrhea

Hepatitis (A or B)

Hepatitis C

Herpes

Mpox (monkey pox)

Syphilis

HPV / General warts

Other

In the past three months, have you had a primary sexual partner?

In the past three months, how many sexual partners have you had?

How often do you consume alcohol?

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?

About PrEP :

How did you hear about PrEP?

Is this your first PrEP consultation?

Have you ever refused taking PrEP in the past?

Have you ever stopped taking PrEP in the past?

Have you ever restarted PrEP after stopping it?

What type of PrEP are you interested in?

Have you ever taken PEP (post-exposure prophylaxis) in the past?

Are you interested in doxy-PEP?

PrEP QUESTIONNAIRE
Initial visit

Clinic opening hours

Telephone reception hours

PrEP QUESTIONNAIRE Initial visit

PrEP QUESTIONNAIRE
Initial visit