Sexual health - PrEP online request form | Kent Community Health NHS Foundation Trust

We are making it easier for people taking PrEP to continue to access this. Should you choose to continue, you will be asked to complete a few questions online. A clinician will then review your completed self-assessment and we will then contact you with advice on what to do next.

Please note that we will be unable to review any symptoms or treat any infections during this type of PrEP appointment. If you have symptoms, need treatment for an infection, are due a vaccination, please call 0300 7900 0245 or 0300 123 1678.

This option is unsuitable for people who get PrEP via commercial trials or who would like to start PrEP (for example, if you have never had PrEP before, or if you have had a break from PrEP).

Consent

Please tick the box to indicate that you have read and understood the above that you have read our Confidentiality statement and that we may contact you on the number provided via call, SMS or leave a voicemail if necessary.

Demographics

Name(Required)

Firstname Surname

Postcode(Required)

Date of birth(Required)

Hidden

OLD INACTIVE Gender

Female
Male
Other/prefer not to say

Gender(Required)

Is gender the same since birth?(Required)

Ethnicity(Required)

Other, please specify

Country(Required)

Medical history

Do you have any medical conditions or diagnoses (including any kidney problems)?(Required)

Yes
No

Please specify medical condition(s)(Required)

Do you take any regular medications (including any herbal remedies, over-the-counter medication and vitamins or supplements or contraception)?(Required)

Yes
No

Please specify medication/supplements(Required)

If you have periods, please tell us when your last period was?

Do you smoke or vape?

Yes
No
Ex-smoker

How often do you have a drink containing alcohol?

Never
Monthly or less
2 to 4 times a month
2 to 3 times a week
4 or more times a week

Have you used any recreational or party drugs in the last three months?

Yes
No

Please select any recreational or party drugs you've used in the last three months

Sexual Health assessment

How many sexual partners have you had in the last three months?(Required)

0
1
2 to 4
5+

Are you currently experiencing any difficulties with sexual performance or satisfaction?(Required)

Yes
No
I do not want to answer

Risk assessment history

Are you currently or have you ever experienced any of the below?

Sexual assault
Domestic abuse
Mental health issues
I do not want to answer

Would you like one of our clinicians to contact you to offer support or advice?(Required)

Yes
No (I am safe and have received or am receiving support with this from other services and do not require contact at present)

PrEP risk and exposure

Do you have any questions, issues or side effects related to your PrEP medication?(Required)

Yes
No

Please specify(Required)

How do you take your Prep?(Required)

Please specify box opens(Required)

Have you missed any pills in the last three months?(Required)

Yes
No

Number of missed pills?(Required)

Reason(s) for missed pills?(Required)

Have you had any unprotected sex during or around the time that you missed your pills?(Required)

Yes
No

Approximate number of days of PrEP remaining?(Required)

Less than two weeks
Two weeks or more

Approximate date of your last HIV test

Result of last HIV test

Which site would you like to attend?(Required)

Completed date(Required)

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Sexual health – PrEP online request form

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