Gender
Sexual preferences
Postcode
Have you had sex in the last 72 hours?
yes
no
Do you have any symptoms of an STI?
yes
no
Title
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...
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First name
Last name
Date of birth
Ethnicity
White
Mixed Parentage
Asian / Asian British
Caribbean
African
Other Black
Chinese / other Ethnic group
I'd rather not say
Get my address
Address line 1
Address line 2
Town/city
County
Postcode
Mobile
Notify me by SMS?
Email
Notify me by email?