{"id":1166,"date":"2025-07-04T16:11:58","date_gmt":"2025-07-04T20:11:58","guid":{"rendered":"https:\/\/cliniquelactuel.com\/form\/"},"modified":"2026-01-21T14:53:42","modified_gmt":"2026-01-21T19:53:42","slug":"form","status":"publish","type":"page","link":"https:\/\/cliniquelactuel.com\/en\/form\/","title":{"rendered":"Questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1166\" class=\"elementor elementor-1166 elementor-889\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ff25c3d e-flex e-con-boxed e-con e-parent\" data-id=\"ff25c3d\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-db29c08 elementor-widget elementor-widget-heading\" data-id=\"db29c08\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">PrEP QUESTIONNAIRE <br>Initial visit<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-62973ae e-con-full e-flex e-con e-parent\" data-id=\"62973ae\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d491d75 elementor-widget elementor-widget-text-editor\" data-id=\"d491d75\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>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. <\/p><p>You must answer each question before submitting the questionnaire.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-d2a11b6 elementor-button-align-start elementor-widget elementor-widget-form\" data-id=\"d2a11b6\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"PreP form - Initial\" aria-label=\"PreP form - Initial\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"1166\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"d2a11b6\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Questionnaire - Clinique l&#039;Actuel\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"1166\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_444a7d9 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_444a7d9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_444a7d9]\" id=\"form-field-field_444a7d9\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"Select an option\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_399555f elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_399555f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_399555f]\" id=\"form-field-field_399555f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2966e39 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2966e39\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2966e39]\" id=\"form-field-field_2966e39\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5ed20e6 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5ed20e6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFile numbers\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5ed20e6]\" id=\"form-field-field_5ed20e6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_95cb15c elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_95cb15c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_95cb15c]\" id=\"form-field-field_95cb15c\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"Select an option\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sexe elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sexe\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat is your sex at birth?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sexe]\" id=\"form-field-sexe\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Female\">Female<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Male\">Male<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prefer not to answer\">Prefer not to answer<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_35f8264 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_35f8264\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat is your gender identity?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_35f8264]\" id=\"form-field-field_35f8264\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Agenre\">Agenre<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bigenre\">Bigenre<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Two-spirited\">Two-spirited<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cisgenre \">Cisgenre <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gender fluid\">Gender fluid<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Non-binary\">Non-binary<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Queer\">Queer<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Transgender\">Transgender<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Xenogenre\">Xenogenre<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prefer not to answer\">Prefer not to answer<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-Origine elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-Origine\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat is your sexual orientation?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[Origine]\" id=\"form-field-Origine\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Aromantic\">Aromantic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Asexual\">Asexual<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bisexual\">Bisexual<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Two-spirited\">Two-spirited<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Heterosexual\">Heterosexual<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Homosexual (gay \/ lesbian)\">Homosexual (gay \/ lesbian)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pansexual\">Pansexual<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Polyamorous\">Polyamorous<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Queer\">Queer<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prefer not to answer\">Prefer not to answer<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-ethnique_culturelle elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-ethnique_culturelle\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat is your ethnic or cultural background?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[ethnique_culturelle]\" id=\"form-field-ethnique_culturelle\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Arab\">Arab<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Southeast Asian (e.g. Cambodian, Laotian, Thai, Vietnamese)\">Southeast Asian (e.g. Cambodian, Laotian, Thai, Vietnamese)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Asian (e.g. Afghan, Lebanese, Iranian, Syrian)\">West Asian (e.g. Afghan, Lebanese, Iranian, Syrian)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Aboriginal (First Nations \/ Inuit \/ M\u00e9tis)\">Aboriginal (First Nations \/ Inuit \/ M\u00e9tis)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"White\">White<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Chinese\">Chinese<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Korean\">Korean<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Japanese\">Japanese<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Jewish\">Jewish<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Latin American \/ Hispanic \">Latin American \/ Hispanic <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Black\">Black<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Filipino\">Filipino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Asian (e.g. Bangladeshi, Indian, Pakistani, Sri Lankan)\">South Asian (e.g. Bangladeshi, Indian, Pakistani, Sri Lankan)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prefer not to answer\">Prefer not to answer<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3571013 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3571013\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat is your legal status in Canada?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3571013]\" id=\"form-field-field_3571013\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Citizen by birth\">Citizen by birth<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Citizen by naturalization\">Citizen by naturalization<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Asylum seeker \">Asylum seeker <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Permanent resident\">Permanent resident<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Temporary resident (temporary worker \/ foreign student \/ visitor)\">Temporary resident (temporary worker \/ foreign student \/ visitor)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Accepted refugee (or protected person)\">Accepted refugee (or protected person)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Indian status (under the Indian Act)\">Indian status (under the Indian Act)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tourist\">Tourist<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prefer not to answer\">Prefer not to answer<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_f008f64 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f008f64\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat is the highest level of education you have completed?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_f008f64]\" id=\"form-field-field_f008f64\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No certificate, diploma or degree\">No certificate, diploma or degree<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Primary\">Primary<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Secondary (DES \/ DEP)\">Secondary (DES \/ DEP)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"College \/ CEGEP (DEC \/ AEC)\">College \/ CEGEP (DEC \/ AEC)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"University (bachelor&#039;s degree)\">University (bachelor&#039;s degree)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"University (master&#039;s degree)\">University (master&#039;s degree)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"University (doctorate \/ post-doctorate)\">University (doctorate \/ post-doctorate)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prefer not to answer\">Prefer not to answer<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3c3a95b elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3c3a95b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat is your annual income (before taxes)?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3c3a95b]\" id=\"form-field-field_3c3a95b\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"$30,000 or less\">$30,000 or less<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"$30,000 to $49,999\">$30,000 to $49,999<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"$50,000 to $69,999\">$50,000 to $69,999<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"$70,000 to $99,999\">$70,000 to $99,999<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"$100,000 to $149,999\">$100,000 to $149,999<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"$150,000 or more\">$150,000 or more<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prefer not to answer\">Prefer not to answer<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_666ef39 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_666ef39\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have private insurance for medications?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_666ef39]\" id=\"form-field-field_666ef39\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prefer not to answer\">Prefer not to answer<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7562e93 elementor-col-100\">\n\t\t\t\t\tHave you ever been diagnosed with the following infections?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5cbcd89 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5cbcd89\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tChlamydia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_5cbcd89]\" id=\"form-field-field_5cbcd89\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_f6bacdc elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f6bacdc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGonorrhea\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_f6bacdc]\" id=\"form-field-field_f6bacdc\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_fef7e23 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fef7e23\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHepatitis (A or B)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_fef7e23]\" id=\"form-field-field_fef7e23\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3685f87 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3685f87\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHepatitis C\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3685f87]\" id=\"form-field-field_3685f87\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_9a6c9ca elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9a6c9ca\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHerpes\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_9a6c9ca]\" id=\"form-field-field_9a6c9ca\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_f5f932b elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f5f932b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMpox (monkey pox) \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_f5f932b]\" id=\"form-field-field_f5f932b\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_f73de53 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f73de53\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSyphilis \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_f73de53]\" id=\"form-field-field_f73de53\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_d19ea1a elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d19ea1a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHPV \/ General warts\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_d19ea1a]\" id=\"form-field-field_d19ea1a\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_559b34e elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_559b34e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOther\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_559b34e]\" id=\"form-field-field_559b34e\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3f7581e elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3f7581e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIn the past three months, have you had a primary sexual partner?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3f7581e]\" id=\"form-field-field_3f7581e\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prefer not to answer\">Prefer not to answer<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_61824db elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_61824db\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIn the past three months, how many sexual partners have you had?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_61824db]\" id=\"form-field-field_61824db\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"None\">None<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">1<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2 to 4\">2 to 4<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5 to 9\">5 to 9<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"More than 10\">More than 10<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prefer not to answer\">Prefer not to answer<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a65bfe5 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a65bfe5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow often do you consume alcohol?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a65bfe5]\" id=\"form-field-field_a65bfe5\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Never\">Never<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 time a month or less\">1 time a month or less<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2 to 4 times a month\">2 to 4 times a month<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2 to 3 times a week\">2 to 3 times a week<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3 to 5 times a week\">3 to 5 times a week<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Daily\">Daily<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_059a4fb elementor-col-100\">\n\t\t\t\t\tIn the past three months, have you used any of the following substances?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_14a18cb elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_14a18cb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCannabis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_14a18cb]\" id=\"form-field-field_14a18cb\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes in a chemsex context\">Yes in a chemsex context<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_27e2788 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_27e2788\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCocaine\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_27e2788]\" id=\"form-field-field_27e2788\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes in a chemsex context\">Yes in a chemsex context<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_cba6c36 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cba6c36\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCrack\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_cba6c36]\" id=\"form-field-field_cba6c36\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes in a chemsex context\">Yes in a chemsex context<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_2a6a638 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2a6a638\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCrystal meth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_2a6a638]\" id=\"form-field-field_2a6a638\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes in a chemsex context\">Yes in a chemsex context<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a55fec8 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a55fec8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGHB\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a55fec8]\" id=\"form-field-field_a55fec8\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes in a chemsex context\">Yes in a chemsex context<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_b8674a6 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b8674a6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHeroin\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_b8674a6]\" id=\"form-field-field_b8674a6\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes in a chemsex context\">Yes in a chemsex context<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_00ef6a3 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_00ef6a3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tKetamine\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_00ef6a3]\" id=\"form-field-field_00ef6a3\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes in a chemsex context\">Yes in a chemsex context<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_695915a elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_695915a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMDMA (ecstasy)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_695915a]\" id=\"form-field-field_695915a\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes in a chemsex context\">Yes in a chemsex context<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5e82946 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5e82946\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOpioids (e.g. fentanyl)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_5e82946]\" id=\"form-field-field_5e82946\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes in a chemsex context\">Yes in a chemsex context<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_833481a elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_833481a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPoppers\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_833481a]\" id=\"form-field-field_833481a\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes in a chemsex context\">Yes in a chemsex context<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8d63171 elementor-col-100\">\n\t\t\t\t\tIn the last three months, have you :\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_f901b1e elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f901b1e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHad sex with someone who is HIV-positive?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_f901b1e]\" id=\"form-field-field_f901b1e\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_92a8f9c elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_92a8f9c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHad sex with someone whose HIV status you did not know?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_92a8f9c]\" id=\"form-field-field_92a8f9c\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_ccef534 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ccef534\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHad sex with a sex worker?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_ccef534]\" id=\"form-field-field_ccef534\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_0df9c0a elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0df9c0a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWorked as a sex worker?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_0df9c0a]\" id=\"form-field-field_0df9c0a\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_91e6f8a elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_91e6f8a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tReceived post-exposure treatment to prevent HIV following a risky activity?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_91e6f8a]\" id=\"form-field-field_91e6f8a\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_2354242 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2354242\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tUsed apps to meet partners (e.g. Grindr)? \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_2354242]\" id=\"form-field-field_2354242\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_d8b553b elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d8b553b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tVisited a sauna?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_d8b553b]\" id=\"form-field-field_d8b553b\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_64c98de elementor-col-100\">\n\t\t\t\t\tIn the past three months :\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_8739287 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8739287\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow often did you use condoms during sex?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_8739287]\" id=\"form-field-field_8739287\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Always\">Always<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Almost always\">Almost always<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Every other time\">Every other time<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Rarely \">Rarely <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Never\">Never<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_65cea5a elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_65cea5a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you had anal sex?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_65cea5a]\" id=\"form-field-field_65cea5a\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, as a penetrating partner (active\/top)\">Yes, as a penetrating partner (active\/top)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, as a receptive partner (passive\/bottom) \">Yes, as a receptive partner (passive\/bottom) <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, as a versatile partner (versa)\">Yes, as a versatile partner (versa)<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_e5e8676 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e5e8676\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you had vaginal (frontal) sex?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_e5e8676]\" id=\"form-field-field_e5e8676\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, as a penetrating partner\">Yes, as a penetrating partner<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, as a receptive partner\">Yes, as a receptive partner<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_489e0b9 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_489e0b9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you had oral sex?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_489e0b9]\" id=\"form-field-field_489e0b9\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, I have given oral sex \">Yes, I have given oral sex <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, I have received oral sex\">Yes, I have received oral sex<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, I both gave and received oral sex\">Yes, I both gave and received oral sex<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_d7f7588 elementor-col-100\">\n\t\t\t\t\tAbout PrEP :\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_c00fd2d elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c00fd2d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow did you hear about PrEP?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_c00fd2d]\" id=\"form-field-field_c00fd2d\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select one\">Select one<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"By a friend\">By a friend<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"By a sexual partner\">By a sexual partner<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"By a doctor or health professional \">By a doctor or health professional <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"On the Internet (search engines)\">On the Internet (search engines)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"On social networks \">On social networks <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_ab048a4 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ab048a4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIs this your first PrEP consultation?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_ab048a4]\" id=\"form-field-field_ab048a4\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_006c8e5 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_006c8e5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you ever refused taking PrEP in the past?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_006c8e5]\" id=\"form-field-field_006c8e5\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_f8c88f2 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f8c88f2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you ever stopped taking PrEP in the past?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_f8c88f2]\" id=\"form-field-field_f8c88f2\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"I never took PrEP\">I never took PrEP<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, because I no longer wished to take PrEP\">Yes, because I no longer wished to take PrEP<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, because my risk of exposure to HIV had decreased\">Yes, because my risk of exposure to HIV had decreased<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, because of health problems for which PrEP is not recommended \">Yes, because of health problems for which PrEP is not recommended <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, because of side effects\">Yes, because of side effects<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, because I found it difficult to take PrEP regularly\">Yes, because I found it difficult to take PrEP regularly<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, because of the frequency of medical follow-ups\">Yes, because of the frequency of medical follow-ups<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, because of the difficulty of accessing treatment\">Yes, because of the difficulty of accessing treatment<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, because of the stigma attached to PrEP\">Yes, because of the stigma attached to PrEP<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes, for financial reasons\">Yes, for financial reasons<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5c64261 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5c64261\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you ever restarted PrEP after stopping it?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_5c64261]\" id=\"form-field-field_5c64261\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"I have never taken PrEP\">I have never taken PrEP<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1694c96 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1694c96\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat type of PrEP are you interested in?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1694c96]\" id=\"form-field-field_1694c96\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Daily (tablet)\">Daily (tablet)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"On-demand (tablet)\">On-demand (tablet)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Long-acting injectable \">Long-acting injectable <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"I don&#039;t know\">I don&#039;t know<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5ec2aa2 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5ec2aa2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you ever taken PEP (post-exposure prophylaxis) in the past?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_5ec2aa2]\" id=\"form-field-field_5ec2aa2\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"I do not know what that is\">I do not know what that is<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5bc6dc2 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5bc6dc2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre you interested in doxy-PEP?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_5bc6dc2]\" id=\"form-field-field_5bc6dc2\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select an option\">Select an option<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"I don&#039;t know, I&#039;d like some information \">I don&#039;t know, I&#039;d like some information <\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Submit<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>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.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"give_campaign_id":0,"footnotes":""},"class_list":["post-1166","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.1 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Questionnaire - Clinique l&#039;Actuel<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/cliniquelactuel.com\/en\/form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Questionnaire - Clinique l&#039;Actuel\" \/>\n<meta property=\"og:description\" content=\"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.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/cliniquelactuel.com\/en\/form\/\" \/>\n<meta property=\"og:site_name\" content=\"Clinique l&#039;Actuel\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/CliniquemedicalelActuel\" \/>\n<meta property=\"article:modified_time\" content=\"2026-01-21T19:53:42+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/cliniquelactuel.com\\\/en\\\/form\\\/\",\"url\":\"https:\\\/\\\/cliniquelactuel.com\\\/en\\\/form\\\/\",\"name\":\"Questionnaire - Clinique l&#039;Actuel\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/cliniquelactuel.com\\\/#website\"},\"datePublished\":\"2025-07-04T20:11:58+00:00\",\"dateModified\":\"2026-01-21T19:53:42+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/cliniquelactuel.com\\\/en\\\/form\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/cliniquelactuel.com\\\/en\\\/form\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/cliniquelactuel.com\\\/en\\\/form\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Accueil\",\"item\":\"https:\\\/\\\/cliniquelactuel.com\\\/en\\\/current-clinic\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Questionnaire\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/cliniquelactuel.com\\\/#website\",\"url\":\"https:\\\/\\\/cliniquelactuel.com\\\/\",\"name\":\"Clinique l'Actuel\",\"description\":\"GMF et Centre d&#039;excellente en sant\u00e9 sexuelle\",\"publisher\":{\"@id\":\"https:\\\/\\\/cliniquelactuel.com\\\/#organization\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/cliniquelactuel.com\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":\"Organization\",\"@id\":\"https:\\\/\\\/cliniquelactuel.com\\\/#organization\",\"name\":\"Clinique l'Actuel\",\"url\":\"https:\\\/\\\/cliniquelactuel.com\\\/\",\"logo\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/cliniquelactuel.com\\\/#\\\/schema\\\/logo\\\/image\\\/\",\"url\":\"https:\\\/\\\/cliniquelactuel.com\\\/wp-content\\\/uploads\\\/2025\\\/02\\\/logo_clinique.avif\",\"contentUrl\":\"https:\\\/\\\/cliniquelactuel.com\\\/wp-content\\\/uploads\\\/2025\\\/02\\\/logo_clinique.avif\",\"width\":277,\"height\":126,\"caption\":\"Clinique l'Actuel\"},\"image\":{\"@id\":\"https:\\\/\\\/cliniquelactuel.com\\\/#\\\/schema\\\/logo\\\/image\\\/\"},\"sameAs\":[\"https:\\\/\\\/www.facebook.com\\\/CliniquemedicalelActuel\"]}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Questionnaire - Clinique l&#039;Actuel","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/cliniquelactuel.com\/en\/form\/","og_locale":"en_US","og_type":"article","og_title":"Questionnaire - Clinique l&#039;Actuel","og_description":"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.","og_url":"https:\/\/cliniquelactuel.com\/en\/form\/","og_site_name":"Clinique l&#039;Actuel","article_publisher":"https:\/\/www.facebook.com\/CliniquemedicalelActuel","article_modified_time":"2026-01-21T19:53:42+00:00","twitter_card":"summary_large_image","schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/cliniquelactuel.com\/en\/form\/","url":"https:\/\/cliniquelactuel.com\/en\/form\/","name":"Questionnaire - Clinique l&#039;Actuel","isPartOf":{"@id":"https:\/\/cliniquelactuel.com\/#website"},"datePublished":"2025-07-04T20:11:58+00:00","dateModified":"2026-01-21T19:53:42+00:00","breadcrumb":{"@id":"https:\/\/cliniquelactuel.com\/en\/form\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/cliniquelactuel.com\/en\/form\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/cliniquelactuel.com\/en\/form\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Accueil","item":"https:\/\/cliniquelactuel.com\/en\/current-clinic\/"},{"@type":"ListItem","position":2,"name":"Questionnaire"}]},{"@type":"WebSite","@id":"https:\/\/cliniquelactuel.com\/#website","url":"https:\/\/cliniquelactuel.com\/","name":"Clinique l'Actuel","description":"GMF et Centre d&#039;excellente en sant\u00e9 sexuelle","publisher":{"@id":"https:\/\/cliniquelactuel.com\/#organization"},"potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/cliniquelactuel.com\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"},{"@type":"Organization","@id":"https:\/\/cliniquelactuel.com\/#organization","name":"Clinique l'Actuel","url":"https:\/\/cliniquelactuel.com\/","logo":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/cliniquelactuel.com\/#\/schema\/logo\/image\/","url":"https:\/\/cliniquelactuel.com\/wp-content\/uploads\/2025\/02\/logo_clinique.avif","contentUrl":"https:\/\/cliniquelactuel.com\/wp-content\/uploads\/2025\/02\/logo_clinique.avif","width":277,"height":126,"caption":"Clinique l'Actuel"},"image":{"@id":"https:\/\/cliniquelactuel.com\/#\/schema\/logo\/image\/"},"sameAs":["https:\/\/www.facebook.com\/CliniquemedicalelActuel"]}]}},"campaignId":"","_links":{"self":[{"href":"https:\/\/cliniquelactuel.com\/en\/wp-json\/wp\/v2\/pages\/1166","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cliniquelactuel.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cliniquelactuel.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cliniquelactuel.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cliniquelactuel.com\/en\/wp-json\/wp\/v2\/comments?post=1166"}],"version-history":[{"count":7,"href":"https:\/\/cliniquelactuel.com\/en\/wp-json\/wp\/v2\/pages\/1166\/revisions"}],"predecessor-version":[{"id":2413,"href":"https:\/\/cliniquelactuel.com\/en\/wp-json\/wp\/v2\/pages\/1166\/revisions\/2413"}],"wp:attachment":[{"href":"https:\/\/cliniquelactuel.com\/en\/wp-json\/wp\/v2\/media?parent=1166"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}