The following survey determines your risk of acquiring hepatitis and your overall health. The questions relate to your lifestyle, environment, and outlook on life. Please answer all of the questions to complete this survey. If you need to start with a clean survey, press the button at the bottom of the page marked CLEAR. When you have finished filling out this survey, press the button at the bottom of the page marked SUBMIT.

1. What is your age (in years)?

2. What is your gender?
Male Female

3. Place of birth?
North America South America
Europe Asia
Africa Other

4. Which of the following best describes your race or ethnic group?
Asian Aleutian, Alaskan Native, Eskimo, or American Indian
Black/African-American Pacific Islander
White Hispanic/Mexican-American
Hispanic/Puerto Rican Hispanic/Cuban
Don't Know Other

5. Do you have, or have you ever been told you have any of the following?

Yes

No

Not sure

Allergies (nonmedication)

Angina (chest pain)

Asthma

Colitis

Diabetes (sugar diabetes)

Heart attack

Hepatitis B or C

High blood pressure

High cholesterol (blood lipids)

Recurrent sun exposure resulting in sunburn

Shortness of breath or trouble breathing


6. Do you believe...

Never

Rarely

Sometimes

Frequently

Almost always

"Bad luck" causes failures?

You fail because of other people?

"Luck" is usually why people are successful?

In the game of life, you take the cards you are dealt?


7. In general, how satisfied are you with your life?
Mostly satisfied Partly satisfied Not satisfied

8a. In the past year, how many days have you missed from work or school related to symptoms of an illness, hospital stay, or emergency room visits?
0 1-3 4-7 8-14 15+

8b. If you did miss work or school, was it due to any of these conditions? (Mark all that apply)
Allergies Liver problems Shortness of breath or
      trouble breathing
Angina (chest pain) Asthma Other

9. In the last year have you drunk or used drugs more than you meant to?
Yes No

10. How many drinks of alcoholic beverages do you have in a typical week?
(A drink is a 12 oz. bottle or can of beer, a 12 oz. wine cooler, a 5 oz. glass of wine, one shot of liquor.)
0 1-3 4-7 8-14 15+

11. Please indicate whether any of the following statements apply to you? (Mark all that apply)
I sometimes drink socially.
I sometimes feel I should cut down on the amount I drink.
I sometimes get annoyed when people criticize me for drinking.
I sometimes feel guilty about the amount I drink.
I sometimes have a drink in the morning to get myself going.
I consider myself an alcoholic.
I am a recovering alcoholic.

12. Have you felt you wanted or needed to cut down on your drinking or drug use in the past year?
Yes No

13. Have you suffered a personal loss or misfortune in the past year that had serious impact on your life? (For example, a job loss, disability, separation, jail term, or the death of someone close to you.)
Yes, 1 serious loss or misfortune.
Yes, 2 or more serious losses or misfortunes.
None.

14. Considering your age, how would you rate your overall physical health?
Excellent Very good Good
Fair Poor  

15. What was the highest level you completed in school?
Grade school or less Some college
Some high school College graduate
High school graduate Post graduate or professional degree

16. Did you receive blood, a blood transfusion, or blood products before 1992?
Yes No Not sure

17. Did you have major surgery before 1992?
Yes No  

18. Do you believe you are at increased risk for hepatitis or HIV? (Healthcare industry work with patient contact, working in a nursing home or group home; having exposure to blood products; prior or actively an IV drug user; being sexually active with multiple partners.)
Yes No Not sure