quiz.jsp

The Quiz!

Section I:

Gender (Check One):	Male Female Transgender
Gender at birth	Male Female
Race/Ethnicity	Asian / Pacific Islander Black / African American White Hispanic / Latino / Latina Black Hispanic / Latino / Latina Native American / Alaskan Native White / Caucasian Other / Mixed Race
In general what language(s) do you speak?	Only English English better than Spanish Both English and Spanish equally. Spanish better than English Only Spanish Other Language
How old are you?	11 - 13 years 14 - 17 years 18 - 25 years Other
Which of the following best describes you sexually?	Straight (Heterosexual) Gay / Lesbian (Homosexual) Bisexual Not Sure or Undecided Other
Are you currently in a relationship?	Yes No Do not know
If yes, how long?	0 - 3 months 4 - 6 months 7 - 9 months 10 - 12 months More than 1 year
Is this the only person you are dating?	Yes No

Section II:

The last time you had sex did you and your partner use a condom or dental dam?	Yes No
How many sexual partners have you had in the last 90 days or 3 months?	0 1 only 1 - 2 3 - 4 5 - 6 More than 6
How would you describe your last sexual partner?	Casual Partner Male Partner One-time Partner
When you have sex, do you use protection such as condoms/rubbers, or dental dams?	Never Some of the time Most of the time Always
How often do you drink alcohol?	Never Daily Weekly Monthly Once a Year
How oftern do you use recreational drugs?	Never Daily Weekly Monthly Once a Year
If you answered "Never" to questions 7 and 8 then go to Section III
How often do you have drugs or alcohol when you have sex?	Never Daily Weekly Monthly Once a Year
Which of the following have you used before or during sex?	Alcohol Marijuana Opiates / Heroin Poppers / Inhalants / Solvents Hallucinogens Downers / Barbiturates Cocaine / Crack Speed / Amphetamines Other illegal drugs I have not used drugs or alcohol before having sex

Section III:

How many times have you been treated for a sexually transmitted disease?	Never 1 time 2-3 times 4-5 times more than 5 times
How long ago was your last HIV test?	Less than a month ago About 6 months ago About a year ago More than a year ago I have never been tested for HIV
Do you know your HIV status at this time?	Yes No
Do you know the HIV status of your last sexual partner?	Yes No

Section IV:

What are the risk factors for sexually trasmitted diseases? (Check all that apply)	Having unprotected sex Drinking alcohol Sharing unprotected sex toys Getting high Touching your partner's unprotected penis or vagina
True or False
I can always tell if someone has an STD by looking closely at their penis or vagina.	True False
I do not need to be tested for STDs, I will know that I have an STD because I will feel it.	True False
Having a STD can increase my chance of getting HIV.	True False
Some STDs can make a woman barren, which means she will never be able to have children.	True False
Oral sex is safe, even without a condom.	True False
50% of all new HIV infections occur in people of what age group (Check one)	Babies of HIV infected mothers Children ages 5 - 13 years old Young people under 25 years old Adults 25 - 35 years old Adults 29 - 45 years old Senior citizens 65 years and older
I can be HIV positive (+) and test negative (-) for up to: (Check one)	2 months 4 months 6 months 1 year

Section V:

Where do you live?

City:
State:
Zip
DC residents only	NW SW NE SE

What is the highest level of education completed?

Junior High School
High School
Some College or Trade School

Which of the following would you like to know more about (Check all that apply)

Information about STDs & risk reduction
How to negotiate safer sex
How to use protection (condoms, dental dams)
STD treatment and services
Where to obtain HIV and other STD counseling & testing services
Other (specify)

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