Form Cdc - Viral Hepatitis Case Report Page 6
ADVERTISEMENT
1
2
3
4
5
6DRAFT COPY
NETSS ID NO.
Patient History- Hepatitis C Virus Infection (chronic or resolved)
STATE CASE NO.
_
________________________________________
The following questions are provided as a guide for the investigation of lifetime risk factors for HCV infection. Routine collection of risk factor
information for persons who test HCV positive is not required. However, collection of risk factor information for such persons may provide useful
information for the development and evaluation of programs to identify and counsel HCV-infected persons.
Yes
No
Unk
Yes
No
Unk
•
•
Did the patient receive a blood transfusion prior to 1992? ...................
Was the patient ever employed in a medical or
•
Did the patient receive an organ transplant prior to 1992? .............................
dental field involving direct contact with human
•
Did the patient receive clotting factor concentrates produced prior to 1987?
blood? ....................................................................
•
Was the patient ever on long-term hemodialysis? ..........................................
•
Has the patient ever injected drugs not prescribed by a doctor
even if only once or a few times? ............................................................
•
How many sex partners has the patient had (approximate lifetime) ? _________
•
Was the patient ever incarcerated? .............................................................
•
Was the patient ever treated for a sexually transmitted disease? .............
•
Was the patient ever a contact of a person who had hepatitis ? ..........
If yes, type of contact
•
Sexual .........................................................................................................
•
Household [Non-sexual] ............................................................................
•
Other: ____________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal