Por favor, activa JavaScript en tu navegador para completar este formulario.Por favor, activa JavaScript en tu navegador para completar este formulario.1Create a Account2Medical Questionaire34567Name : *Email *Address :Password *NextBy signing this document I agree to the term and documents on the below. HIV : Address SignatureClear Signature Consentimiento informado. Privacidad NextSex :MasculineFemenineGenderMenWomenTransgenderNon BinarySexualityGayBisexualHeteosexualDate Of BirthHeightWeightMarriage StatusYesNoLevel of EducationNextHave you been expose HIV in last 30 days ?yesnoDo you have sex with ?MenWomenBothTopBottomBothNumbers of Sexual partners in last 6 monthsHave you had sex without condom in the last six month ?yesnoDoes your Partner has HIV ?YesnoNextHave you been diagnose with and STD in the last six month which one ? do you recieved treatment ?Do you have hepatitis B & C ?yesnoDo you have liver problems ?yesnoDo you have kidney problems ? yesnoNextDo you take any medication ?yesnoDo you take supplenments ?yesnoare you allergy any medication ?yesnohave you consumed any type of drugs last 12 months ? which ones ?NextChose the Laboratory Location for the test.StateSelect StateCitySelect CityLocationSubmit
