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