Caring Ambassadors Program, Hepatitis C Division Should You Be Tested For Hepatitis C?

What is Hepatitis C?

Hepatitis C is an infection of the liver caused by the hepatitis C virus (HCV). The hepatitis C virus can slowly cause liver damage over many years without causing any symptoms. The liver can eventually be damaged to the point that it can no longer perform its many jobs. There is no vaccine to prevent hepatitis C, but medical treatments are available to help prevent severe liver damage.

How Do You Get Hepatitis C?

Since people with hepatitis C generally do not feel sick, people can have the virus and unknowingly spread it to others. The hepatitis C virus is spread by blood-to-blood contact. The following series of questions will help you determine if you may have been exposed to the hepatitis C virus. People who may have been exposed to HCV should be tested.

Could You Have Been Exposed to the Hepatitis C Virus?

Check the box next to each statement that applies to you. Your responses are confidential.

• I had a blood transfusion before 1992.
• I received blood products (immunoglobulin, anti-Rh factor, plasma, or platelets) before 1992.
• I am a hemophiliac.
• I have been on kidney dialysis.
• My mother has hepatitis C.
• Someone I live with now or have lived with in the past has hepatitis C.
• I have injected or snorted street drugs (even once, even if it was many years ago).
• I am a military combat veteran.
• I have or have had a job that exposed me to blood (examples include health care workers, police officers, fire fighters, paramedics, and EMTs).
• I have been incarcerated.
• I participate or used to participate in a recreational activity (contact sports) that may have exposed me to blood.
• I have shared personal hygiene equipment such as a razor, toothbrush, hair clippers, cuticle scissors, or nail clippers with others.
• I have a tattoo that is more than 5 years old, or that was done in someplace other than a professional tattoo parlor.
• I have had a body piercing (includes ears) that was not done by a professional.
• I share body piercing jewelry with others.
• I have had multiple sexual partners (10 or more sexual partners in my lifetime or more than 1 sexual partner in the last 6 months).
• I have been exposed to blood during sexual activity.
• I have had injections, surgery, or dental work done outside the U.S.
• I have had abnormal liver blood tests.
• None of the above applies to me, but I would still like to be screened for hepatitis C.

Contact Information: Please PRINT Clearly

First Name: _________________
Last Name: ___________________________
Date of Birth: ___/___/___ Sex: male female
Race: Caucasian African-American Hispanic
Asian/Pacific Islander Other
Mailing Address: ______________________________________________
Apartment Number: _________
City: __________________________________________ State: _____ Zip Code:___________
Telephone Number: (__ __ __) __ __ __ - __ __ __ __
OK to leave message? yes no

INFORMED CONSENT VERBAGE HERE

Client Signature: _______________________________
Date: ___/___/___

Counselor Signature: ___________________________________

INSERT SPECIMEN IDENTIFIER AND DATE HERE