Hep C Risk Assessment Form

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