Form Cdc - Viral Hepatitis Case Report Page 5
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6DRAFT COPY
NETSS ID NO.
Patient History- Acute Hepatitis C
STATE CASE NO.
_________________________________________
2 weeks- 6 months
During the
prior to onset of symptoms
Ask both of the following questions regardless of the patient’s gender.
6 months
was the patient a contact of a person with confirmed or
0
1
2-5 >5 Unk
In the
before symptom onset how many
•
Yes
No
Unk
suspected acute or chronic hepatitis C virus infection?
male sex partners did the patient have? ...............
•
If yes, type of contact
female sex partners did the patient have? ...........
•
Sexual .........................................................................
Was the patient EVER treated for a sexually
Yes
No Unk
•
Household [Non-sexual] ..........................................
transmitted disease? ....................................................................
•
Other: _______________________________
•
Y Y Y Y
If yes, in what year was the most recent treatment ? __ __ __ __
2 weeks- 6 months
During the
prior to onset of symptoms
•
inject drugs not prescribed by a doctor? ........................
•
use street drugs but not inject? .......................................
2 weeks- 6 months
2 weeks- 6 months
During the
prior to onset of symptoms
During the
prior to onset of symptoms
Yes
No
Unk
•
Did the patient-
Did the patient have any part of their body pierced
•
undergo hemodialysis? ...................................................
(other than ear)?
•
have an accidental stick or puncture with a needle
where was the piercing performed? (select all that apply)
or other object contaminated with blood? ...............
commercial
correctional
other ________________
•
receive blood or blood products [transfusion] ............
parlor / shop
facility
Yes
No
Unk
M M / D D / Y Y Y Y
• if yes, when?
•
Did the patient have dental work or oral surgery? .............
•
receive any IV infusions and/or injections in the outpatient setting...
•
Did the patient have surgery ? (other than oral surgery) ..
•
have other exposure to someone else’s blood ............
•
Was the patient- Check all that apply
specify: ____________________________________
•
hospitalized ? .............................
2 weeks - 6 months
During the
prior to onset of symptoms
•
a resident of a long term care facility ? ...........................
•
Was the patient employed in a medical or dental field
•
incarcerated for longer than 24 hours ? ..........................
involving direct contact with human blood ? ...............
if yes, what type of facility (check all that apply)
If yes, frequency of direct blood contact?
prison ..............................................................
Frequent (several times weekly)
Infrequent
jail ....................................................................
•
juvenile facility ..............................................
Was the patient employed as a public safety worker
(fire fighter, law enforcement or correctional officer)
having direct contact with human blood? ..........................
If yes, frequency of direct blood contact?
During his/her lifetime, was the patient EVER
•
Frequent (several times weekly)
Infrequent
incarcerated for longer than 6 months ? ...........................
•
•
If yes,
Did the patient receive a tattoo? ...................................
Y Y Y Y
__ __ __ __
what year was the most recent incarceration ? ....................
where was the tattooing performed? (select all that apply)
commercial
correctional
other ________________
for how long ? ..................................................................... __ __ __ mos
parlor / shop
facility
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