Register for an AHF Testing Account
Fill in the information below for a totally confidential, highly secure account with AHF. Asterisks indicate required fields.
Full Name: *
Security Questions:

*


*

Email Address:  *
Phone Number:  + (  Ext.
Address:
Type:
Address 1:   
Address 2:
City:
State & Zip Code:   
Country:
Social Security Number: *
Date of Birth:     *
Sex at Birth: *
Gender: *
Sexual Orientation:
Country of Origin:
Nationality:
Languages Spoken:    
Ethnicity:
Race:
  American Indian
  Asian
  Black/African American
  Native Hawaiian
  White/Caucasian
  Other
  Don't Know
  Refused to Answer
Level of Education:
Drug Use:
In the PAST 12 MONTHS, have you:
Used Methamphetamine?
(ie. crack, crank, speed, tina, ice, glass)
YesNo
Used Crack?
(ie. rock, base, bebe, hardball)
YesNo
Used Heroin?
(ie. smack, tar, junk, H, capital H)
YesNo
Used Cocaine?
(ie. blow, candy, coke, snow)
YesNo
Injected any drug?
(ie. including hormones, steroids)
YesNo
Shared needles?
(ie. injection equipment, spoons, cookers, rigs)
YesNo
 
Sexual Behavior:
(Mark all that apply)
In the PAST 12 MONTHS, have you had sex:
  Yes No
Wearing a condom?
Without wearing a condom?
With a person who injects drugs?
With a person who is HIV-Positive?
With a man who has had sex with another man?  
While under the influence of methamphetamine?
While under the influence of alcohol?
 
Confirmation Email:  Yes! Send my Confirmation Email (required for account registration)