Come in today and ask us about the vaccine to protect against Hepatitis!
(Circle) Male or Female
Site Name______________                                        Client ID_________________
Hepatitis Risk Assessment
 

Check your risk of Hepatitis A
Yes
No
 
1.
 
Do you believe you have been exposed to hepatitis A in the past 2 weeks?
 
 
2.
Do you live with someone currently ill with hepatitis A?
 
 
3.
Have you had sex with someone currently ill with hepatitis A?
 
 
4.
Do you currently live in a region of the United States where hepatitis A rates are very high?
 
 
5.
Do you travel or work in an area outside of the U.S. where hepatitis A is a problem? (This includes everywhere EXCEPT Australia, New Zealand, Western Europe, Japan, and Canada)
 
 
6.
If you are a man, do you have sex with other men?
 
 
7.
Are you an injecting or non-injecting (snort cocaine) drug user?
 
 
Check your risk of Hepatitis B
Yes
No
1.
 
Is someone in your household infected with Hepatitis B?
 
 
2.
Have you ever been diagnosed with a sexually transmitted disease?
 
 
3.
Have you had sex with more than one partner in a 6-month period?
 
 
4.
If you are a man, do you have sex with other men?
 
 
5.
Have you or any of your sex partner(s) ever injected illegal drugs?
 
 
6.
Have you ever shared equipment (needles, syringes, cotton, water, etc) when injecting drugs with someone else?
 
 
7.
Have you ever received hemodialysis?
 
 
8.
Did your mother have Hepatitis B when you were born?
 
 
9.
Have you worked in a health care or other occupation where you had a needle stick injury or other sharps exposures on the job?
 
 
10.
Have you shared a toothbrush, razor, or any other item that might have blood on it (visible or not) with a person who has hepatitis B?
 
 
Check your risk of Hepatitis C
Yes
No
 
1.
 
Did you receive a blood transfusion or solid organ transplant (heart, lung, liver, pancreas, kidney) before July 1992?
 
 
2.
Did you receive clotting factor concentrates produced before 1987?
 
 
3.
Have you ever received hemodialysis?
 
 
4.
Have you had blood tests that showed a liver problem?
 
 
5.
Have you had a needle stick injury working in a health care setting?
 
 
6.
Did your mother have Hepatitis C when you were born?
 
 
7.
Have you shared a toothbrush, razor, or any other item that might have blood on it (visible or not) with a person who has hepatitis C?
 
 
8.
Have you or any of your sex partner(s) injected illegal drugs, even if it was only one time many years ago?
 
 
Check if you are at risk
Yes
No
 
1.
You could be at risk if you have, in the last 12 months, had vaginal or anal sex…
Without using a condom?
 
 
2.
With a person of unknown HIV status?