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Pre-Visit Checklist
Your doctor may ask you the following questions to assess your risk of having acquired hepatitis B and C. You may want to print out this list, answer the questions, and bring it with you when you visit your doctor.
| 1. |
Have you had a blood transfusion prior to 1975 (for hepatitis B) or 1992 (for hepatitis C)?
 Yes
No
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| 2. |
Currently or in the past, have you:
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Experienced chronic fatigue or tiredness for which your doctor was unable to find an explanation? |
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Had surgery, including oral surgery? |
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Had a Cesarean section or other obstetric or gynecological surgery? |
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Been diagnosed as HIV-positive? |
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Had kidney dialysis? |
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Had an elevated liver enzyme test (ALT)? |
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Been diagnosed with hepatitis B or C? |
| 3. |
Currently or in the past, have you: |
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Had a tattoo? |
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Had body piercing? |
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Served in the military? |
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Changed sex partners frequently? |
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Inhaled cocaine? |
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Been in prison? |
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Injected drugs? |
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Had a problem with alcoholism? |
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Had unprotected sex with anybody who would fit the above descriptions? |
| 4. |
Do any of the previous categories apply to a member of your immediate family, or has a member of your immediate family been diagnosed with hepatitis B or C?
Yes
No
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| 5. |
Does your work ever put you into contact with blood, blood products, or needles?
Yes
No
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Examples include:
- Armed forces
- Health care workers
- Emergency services
- Prison services
- Science laboratories
- Tattooists
- Beauticians, barbers
- Institution workers (nursing homes/elderly care, psychiatric hospitals, substance abuse centers, hospice workers)
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