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Hep C Risk Assessment Questionnaire

To determine if you might be at risk of being infected with hepatitis C, take a few moments to answer this simple questionnaire. If your results indicate you may be at risk for hepatitis C, you will want to print out this questionnaire and take it to your doctor to discuss. Remember for the sake of your health, be completely honest in answering the questions that follow:

1. Have you had a blood transfusion prior to 1992?
  A. Yes
B. No


2. Currently or in the past, have you:
  Experienced chronic fatigue or tiredness for which your doctor was unable to find an explanation?
Had surgery, including oral surgery prior to 1992?
Had a Cesarean section or other obstetric or gynecological surgery prior to 1992?
Been diagnosed as HIV-positive?
Had kidney dialysis?
Had an elevated liver enzyme test (ALT)?
Been diagnosed with hepatitis B?


3. Currently or in the past, have you:
  Had a tattoo (contaminated needle/ink)?
Had body piercing (contaminated needle)?
Served in the military?
Changed sex partners frequently?
Inhaled cocaine?
Been in prison?
Injected drugs, even once?
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 hepatitis C?
  A. Yes
B. No


5. Does your work ever put you into contact with blood, blood products, or needles?
(Examples include armed forces, health care and hospice workers, emergency service workers, science laboratory personnel, tattooists, beauticians, barbers, and workers in institutions such as nursing homes/elderly care, psychiatric hospitals, and substance abuse centers.)
  A. Yes
B. No