Hepatitis C Risk


	Your Name*
	Phone*
	E-mail Address*

	1. Did you have any solid organ transplant such as kidney, liver, heart, etc., especially before 1997?
	Yes No
	2. Did you receive any blood transfusion (may be during child-birth, due to anemia, etc.) or any blood product, clotting factors, especially made before 1997?
	Yes No Not sure
	3. If your answer is yes to one or both of above: Has it been discovered that the donor was HCV positive?
	Not applicable Yes Not known
	4. Have you had or been on kidney dialysis?
	Yes No
	5. In the past have you received medicines by injections/syringes (by your local doctor/hospital), which may not have been sterile?
	Yes No
	6. Have you indulged into drugs using/sharing unsafe syringes?
	Yes No
	7. Please select one of the most suitable answers:
	I am a health worker with a possible risk of exposure to HCV patients I have/had multiple sex partners I have a steady HCV infected partner I am a baby born to HCV positive mother None of the above
	8. Please select:
	I have explained or unexplained long term liver disease I do not have nor had any long term liver disease