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. 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 XXX1 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 XXX2 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? XXX3 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? XXX4  3   Terms and Conditions | Privacy Policy | Important Safety Information

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