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$200 Study
1.
Contact Info
Name
Phone
E-Mail
State
Age
*
2.
Which gender do you identify with?
(Required.)
Male
Female
Transgender male
Transgender female
Non-binary
Other (please specify)
*
3.
Who have you had sex with in the past 5 years? (Please select all that apply)
(Required.)
Men
Women
Transgender men
Transgender women
Non-binary
No one / I have not had sex in the past 5 years
*
4.
Have you ever been diagnosed by a healthcare provider with any of the following conditions? Your healthcare provider can be a doctor, physician’s assistant, or anyone else that provides medical care to you. (Please select all that apply.)
INFO ONLY
(Required.)
Hepatitis B (HBV)
Anxiety/Depression
Diabetes
High blood pressure
Hepatitis C (HCV)
High Cholesterol
HIV / AIDS
Liver Disease
Obesity
None of these