Hepatitis B (HBV) and Hepatitis C (HCV)Health Screening
Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Birth Date
*
Please select a month
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Month
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Day
Please select a year
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Year
Current Age:
*
Sex at birth:
*
Please Select
Male
Female
Current Gender Identity:
*
Male
Female
Transgender, male to female
Transgender, female to male
Client declines to answer
Other
Race:
*
American Indian / Alaskan Native
Asian
Black
Native Hawaiian / Pacific Islander
White
Multi-Racial
Other
Ethnicity:
*
Hispanic
Non-Hispanic
Vaccinated for HBV?
*
Yes
Partially
No
Don't know
Declined
Back
Next
Risk Factors
Reported Risk
*
Received tattooing in substandard conditions
Injected drugs
Snorted or inhaled drugs
Incarcerated for more than 24 hours
Had sex partner and/or household contact who was diagnosed with HBV or HCV
Had sex with a male
Multiple sex partners
None reported
Other service referrals provided
*
Behavioral Health
Harm Reduction
Substance Use Treatment
Other Medical/Health Services
PrEP/nPEP/DoxyPEP
Housing Services
Other Social Services
Client ever been tested for HCV?
*
Yes
No
The client is not sure
The client was not asked
Other
Do you have any questions, concerns, or needs?
*
Yes
No
Include other questions, concerns, or needs here:
Signature
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