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?

Yes
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 or hepatitis C?

3. Currently or in the past, have you:

Had a tattoo?

Had body piercing?

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?

Yes
No

5. Does your work ever put you into contact with blood, blood products, or needles*?

Yes
No

* Examples include:
-- Armed forces
-- Health care workers
-- Emergency service workers
-- Prison service workers
-- Science laboratory personnel
-- Tattooists
-- Beauticians, barbers
-- Institution workers (nursing homes/elderly care, psychiatric hospitals, substance abuse centers, hospice workers)