Win R1,500 by answering this anonymous Health Market Research Survey

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Our survey will only take 1 minute. Please answer this form as truthfully as possible as your insights will help to shape our affordable and discrete STI testing service. Your responses will remain anonymous and will not be shared with any 3rd party.

Which city in South Africa do you live in? *

What is your gender? *

Female

Male

Other

Prefer not to say

How old are you? *

How many sexual partners do you have a year? *

2-5

5-10

10-20

More than 20

How often do you get tested for an STD/ STI? (HIV, HPV, Gohnnoreah etc.) *

Never

Less than 1 time per year

1 time per year

2 times per year

Every time I have a new sexual partner

What hinders you from getting an STD test? *

Fear

Stigma

Finances

Accessibility

Other

Required

If you wrote "other" please specify

If you would like to be considered for the cash prize of R1,500 and our special testing offer please leave your email address or cell phone number.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Deep Medical Therapeutics. Report Abuse

Forms