|
Hepatitis C Risk Assessment Form
Lifestyle
Currently or in the past have you:
- Been exposed to improperly sterilized (not autoclaved) equipment while
having a tattoo, dental work, or body piercing?
- Snorted cocaine or other drugs with a shared straw or rolled paper?
- Injected IV drugs even one time?
- Shared a toothbrush, razor or any item, which may contain infected blood?
- Been in the military?
- Had multiple sex partners?
- Been in prison?
- Had unprotected sex with anyone who you know who fits the descriptions
above?
Has your work ever put you in contact with blood, blood products, or needles?
Such as:
- Health Care: Doctors, Nurses, Dentists or Dental workers, Oral Surgeons,
Hospital Cleaning Services
- Institution Workers: Nursing Home/Elderly Care, Psychiatric Hospitals,
Substance Abuse and Treatment Centers or Hospice
- Science Laboratories
- Clinical Laboratories
- Tattoo Artists
- Beauticians or Barbers
- Emergency Services, Firefighters, Police Officers or Paramedics
- Prison Services: Corrections Officers, Prison Janitorial staff and
cleaning persons
- Armed Forces: Army, Navy, Air Force, Reserves, Coast Guard
Currently, or in the past, have you experienced any of the following?
- Blood transfusion before 1992?
- Elevated liver enzymes test (ALT)
- Any surgery, including dentistry or Cesarean birthing, where blood or
blood product were administered
- Hemodialysis (treatment with a kidney machine)
- Chronic fatigue/tiredness for which your doctor was unable to find an
explanation
- Diagnosis of HIV-positive
- Diagnosis of hepatitis B or C (non A or B)
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? If so you may wish to get tested just to be safe and to know.
Questions? Call: Frontline Hepatitis Awareness at:
National Helpline: 1-866-hep-gogo (437-4646)
Need someone to speak at your office or company? If you wish to be directed
to a support group also call the above number for referral. If you need help,
Call us please!
|
