Hepatitis C Risk Factors

HEPATITIS C RISK ASSESSMENT FORM
Nearly 4 million Americans have hepatitis C – four times the number of people with HIV. Many people infected with the hepatitis C virus have no symptoms, but years later they can suffer from cirrhosis, liver cancer, or liver failure. That’s why it’s important to find out if you have hepatitis C, and to seek treatment if you do.
Please answer the following questions truthfully. If you answer YES to one or more of the questions, be sure to tell your doctor.
WORK HISTORY
Has your work ever put you in contact with blood, blood products, or needles?
Examples:
Military Duty
Health Care– doctors, nurses, dentists, dental workers, oral surgeons, hospital cleaning services.
Emergency Services– police officers, firefighters, paramedics
Prison Services- corrections officers, prison cleaning services
Institution Workers- nursing homes, elderly care, psychiatric hospitals, substance abuse centers, hospice
Tattooists, Beauticians, Barbers
_________Yes                               _________No
MEDICAL HISTORY
Have you experienced one or more of the following?
Blood transfusion prior to 1992
Unexplained chronic fatigue/ tiredness
Diagnosis of HIV
Hemodialysis
Diagnosis of Hepatitis
Family member with any of the above
_________Yes                           __________No
LIFESTYLE
Does one or more of the following apply to you?
Had a tattoo
Had multiple body piercings
Shared razor, toothbrush, nail clippers, scissors or any item that could carry infected blood
Were sexually active with multiple partners
Inhaled cocaine
Injected drugs (even once)
Sharing glass pipes
Were in prison
Had unprotected sex with anyone who fits any of the above descriptions
________Yes                            __________No
SYMPTOMS REPORTED by PEOPLE LIVING with HCV ACUTE HEPATITIS C
Flu-like illness                                               Diarrhea
Fatigue (mild to severe)                                 Indigestion or Heartburn
Fever                                                              Headaches
Night sweats                                                  Muscle or joint pain
Loss of appetite (anorexia)                           Abdominal bloating
Nausea                                                           Jaundice
Vomiting                                                       Abdominal pain
CHRONIC HEPATITIS C
     All of the above plus the following:
Depression
Mood swings
“Brain fog”
LATE STAGE HEPATITIS C WITH CIRRHOSIS
      All of the above plus the following:
Fluid retention (edema) excess fluid trapped in tissues
Abdominal fluid accumulation (ascites)
Frequent urination
Bleeding varices (swollen veins in esophagus or stomach)
Cognitive dysfunction
Lack of concentration
Mental confusion
Dizziness
Peripheral vision problems
Poor sleep cycles
Bleeding problems