Hepatitis B (HBV) and Hepatitis C (HCV)Health Screening

Hepatitis B (HBV) and Hepatitis C (HCV)Health Screening
Date

MonthDayYear
Date
Name*

First NameLast Name
Birth Date*

MonthDayYear
Sex at birth:*
Current Gender:*

MaleFemaleTransgender, male to femaleTransgender, female to maleClient declines to answerOther
Race:*

American Indian / Alaskan NativeAsianBlackNative Hawaiian / Pacific IslanderWhiteMulti-RacialOther
Ethnicity:*

HispanicNon-Hispanic

Risk Factors
HBV and HCV risk:*

requested a test regardless of risk factorshad a tattoo or piercing outside of a licensed parlorinjected drugs or used drugs intravenously that were not prescribed by a medical providersnorted or inhaled drugsshared equipment for preparing, injecting, or snorting drugs, steroids, hormones, silicone, or other substanceshas ever stayed in jail or prisonhad sex for drugs, money, housing, or other things they neededhas HIVhas been on long-term hemodialysishas been told they have liver damage or elevated ALT/ASTis pregnant and should be tested for HBV and HCV during each pregnancyOther
HBV Risk:*

not previously vaccinated against HBVborn outside the United Statesborn to a mother with HBVborn to parents from countries with high rates of HBVhad sex with or lives with someone who has HBVOther
HCV Risk:*

had unprotected sex with someone who has HCVborn to a mother with HCVreceived a blood transfusion, organ donation, or clotting factors before 1992Other
Has the client ever been tested for HCV?*

YesNoThe client is not sureThe client was not askedOther
Do you have any questions, concerns, or needs?*

YesNo
Include other questions, concerns, or needs here:*
Signature*

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