- HIV Positive Questionnaire

HIV Positive Questionnaire

A portion of the proceeds (35%) will benefit the PWA Holiday Charities of Houston for the specific purpose of supporting their on-going PWA Camp-out because the idea of the book was developed during conversations at the camp-out with some of the attendees. Other supporting agencies will benefit as well.

Thank you for participating by providing your story. The stories can be anonymous or we can utilize your real identity, so please indicate your preference below. We will need your real name and contact information for legal reasons, but if you check ‘anonymous’ below then we will change your name in the book. All personal information will be kept Confidential and not provided to anyone else other than when a video story is created and then only to contact you to see if you would be interested in doing a video. There are a few questions that will help tell your story, so please take your time.

HIV Positive Questionnaire

First Name

Last Name

Address

City

State

Zip Code

Country

Would you like us to use your Real Name?YesNo, Anonymously

E-mail

Telephone

Age

Birth Date

Where were you born?

Gender

Your Signature, by typing your Full Name in this box and checking the box below, you indicate that this is your legal signature.

Yes, I confirm that typing my name above that this is my legal signature.Yes, this is my legal signature.

Please tell us about your upbringing. What was it like for you as a child, a teenager, an adult?

When did you contract HIV or when were you notified that you had HIV?

Tell us about when you had The Conversation with your family:

Tell us about when you had The Conversation with your friends:

Please provide a story about when you had The Conversation with a potential partner:

How did you first feel when you started having The Conversation?

How do you feel now when you have The Conversation?

Has any thing such as therapy assisted you dealing with the fact that your partner is HIV positive?

What advice would you give others to help them to have The Conversation?

Thank You for completing the Questionnaire.

Thank you for providing your story. It’s our hope that through the compiling of these stories that we can help change how others view those of us with HIV and AIDS by helping them understand what it is like for each of us to have “The Conversation”.

After the book has been compiled, written, and published then an announcement will be sent to each participant, along with a signed copy of the book.