Are You at Risk for Hepatitis C?





		Hepatitis Risk Assessment
			Are You at Risk for Hepatitis C?
			Major Risk Factors for Hepatitis A, B and C

Are You at Risk for Hepatitis C?

To determine if you might be at risk of being infected with hepatitis C, take a few moments to answer this simple questionnaire. Remember, for the sake of your health, be completely honest in answering the questions that follow.

1. Medical History
Currently, or in the past, have you experienced any of the following?

Blood transfusion prior to 1992
Chronic fatigue/tiredness for which your doctor was unable to find an explanation
Any surgery, including oral surgery
Cesarean delivery or other obstetric or gynecological surgical intervention
Diagnosis of HIV-positive
Kidney dialysis
Elevated liver enzymes test (ALT)
Diagnosis of hepatitis B or hepatitis C

Yes

No

2. Work History
Does your work ever put you in contact with blood, blood products, or needles? Examples include:

Armed Forces: Army, Navy, Air Force, Reserves, VA Hospital or Home, Coast Guard
Health Care: Doctors, Nurses, Dentists or Dental Workers, Oral Surgeons, Hospital Cleaning Services
Emergency Services: Police Officers, Firefighters, Paramedics
Prison Services: Corrections Officers, Firefighters, Paramedics
Science Laboratories
Clinical Laboratories
Beauticians, Barbers
Institution Workers: Nursing Homes/Elderly Care, Psychiatric Hospitals, Substance Abuse Centers, Hospices

Yes

No

3. Lifestyle
Currently, or in the past, have you:

Had a tattoo?
Had any part of your body pierced?
Been in the military?
Changed sex partners frequently?
Inhaled cocaine?
Been in prison?
Injected drugs (even once)?
Had a problem with alcoholism?
Had unprotected sex with anybody who you know would fit any of the descriptions above?

Yes

No

4. Family History
Do any of the above descriptions apply to a member of your immediate family, or has a member of your immediate family been diagnosed with hepatitis B or hepatitis C?

Yes

Are You at Risk for Hepatitis C?
Without a test, there's no way to tell.

If you answered "yes" to any of the questions, bring this form to your doctor for evaluation and testing. In many instances, hepatitis can be treated, and the medical treatment options now available are helping to fight this disease better than ever before.