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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
No
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.
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