Are you in one of the following areas in the State of Florida? *

First Name

Last Name

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Gender

Date of birth

Height

Weight

How many cigarettes do you smoke per day?

Have you ever been diagnosed with HIV?

Yes

No

Do you currently have a prescription for PrEP?

Yes

No

Name of medication

Name of the Pharmacy managing your prescriptions

Pharmacy phone number

Do you think your current lifestyle puts yourself at risk of HIV? *

Yes

No

Have you ever been diagnosed with the following conditions? *

Are you currently taking any prescription medications, over the counter drugs or herbal supplements, including supplements on a regular basis? *

Yes

No

Please list all medications you are currently taking

Do you have any drug allergies? *

Yes

No

Please list your known medication allergies

Anything else we should know about your medical history? *

Yes

No

Let us know about any concern you may have!

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