Hepatitis A Risk Survey

Question Title

* 1. Do you use recreational or street drugs?

Yes

No

Sometimes

Question Title

* 2. Are you homeless or do you move around a lot?

I am homeless

I often move around, or stay with other people

No

Question Title

* 3. If you are a man, do you have sexual encounters with other men?

Yes

No

Sometimes

Not Applicable

Question Title

* 4. Have you recently been in jail or prison for any amount of time?

Yes

No

Question Title

* 5. Do you have a chronic liver disease? (Such as cirrhosis)

Yes

No

Question Title

* 6. Do you live with someone who uses illegal drugs, or has recently been in jail or prison?

Yes

No

Question Title

* 7. Do you provide direct service to people who use drugs, people who are homeless, or people who were recently in jail or prison?

Yes

No