1258 High Street, Eugene, OR 97401
Phone 541-342-8437 | Fax 541-242-2999
Infectious Disease Risk Assessment
The following questions are necessary to assess your risk for infectious diseases. Please answer these questions. Confidentiality laws protect all answers.
Name: Date of Birth: Date:
Infectious Disease Risk
Have you seen a health care provider in the past three months?
Do you or have you lived on the street or in a shelter?
Have you ever been in jail/prison/juvenile detention?
Have you ever been in a long-term care facility (mental health hospital, nursing home, rehab)?
In the past 3 months, have you traveled outside the US?
If yes, where?
Are you a combat veteran?
In the past year, have you had a tattoo, body piercing, acupuncture, or contact with blood?
Where were you born?
How long have you been in the US?
Have you lived with anyone diagnosed with TB in the past year?
Have you ever been treated for TB?
Have you ever been told you have Hepatitis A?
Have you ever been told you have Hepatitis B?
Have you ever been told you have Hepatitis C?
Have you ever used needles to shoot drugs?
Have you ever shared needles or syringes to inject drugs?
Have you ever had a job where you were at risk for needle sticks or blood contact?
In the past year, have you or anyone you had sex with had an STD or Hepatitis?
In the past 30 days, have you had any of these symptoms lasting more than 2 weeks?
Nausea:
Fever:
Drenching night sweats that were so bad you had to change clothes or bed sheets:
Productive cough:
Coughing up blood:
Shortness of breath:
Lumps or swollen glands in the neck or armpits:
Loss of weight without trying:
Diarrhea lasting more than a week:
Brown tinged urine:
Extreme fatigue:
Jaundice or yellow eyes:
Women: Missed periods for last two months:
HIV/AIDS/Hepatitis C Risk
Did you receive a blood transfusion before 1992?
Have you received blood products produced before 1987 for clotting problems?
Was your birth mother infected by Hepatitis C during the time of your birth?
Have you been or are you currently on long-term kidney dialysis?
Have you had unprotected sex with someone who has the blood disease hemophilia?
Have you had unprotected sex with a person who injects drugs?
Have you had unprotected sex with a man who has sex with other men?
Have you had sex in exchange for money or drugs in order to survive?
Have you had unprotected sex with more than one partner in the past 6 months?
Have you had sex or shared needles with a person who has AIDS, HIV+, or Hep C +?
Have you ever injected drugs, even once?
Have you ever been pricked by a needle that may have been infected with HIV or Hep C?
Have you ever had a test for HIV?
If yes, was it within the last six months?
If no, would you like to be tested?
Have you ever had a blood test for Hepatitis C?
If yes, was it within the last six months?
If no, would you like to be tested?
How would you judge your own risk for being infected with HIV? (Please check one)
How would you judge your own risk for being infected with Hepatitis C? (Please check one)
