| Q31 | HCV viral load | Known = 1 Unknown = 2 | [___] Specify the value if known:…… |
| Q32. | Prior serological status to HDV of the pregnant woman | Positive = 1 Negative = 2 Unknown = 3 | [___] |
| Q33. | Previous HIV serological status of the pregnant woman | Positive = 1 Negative = 2 Unknown = 3 | [___] |
| Q34. | Previous HBV vaccination | Yes = 1 No = 2 | [___] |
| Q35. | HBV serological status of partner | Positive = 1 Negative = 2 Unknown = 3 | [___] |
| Q36. | HCV serological status of partner | Positive = 1 Negative = 2 Unknown = 3 | [___] |
| Q37 | HIV serological status of partner | Positive = 1 Negative = 2 Unknown = 3 | [___] |
| Q38 | Hepatitis C in those around you | Positive = 1 Negative = 2 Unknown = 3 | [___] |
| IV. SOCIAL SURVEY | |||
| Q39. | Do you use drugs by injection? | Yes = 1 No = 2 | [___] |
| Q40. | Do you consume alcohol? | Yes = 1 No = 2 | [___] |
| Q41. | How many sexual partners have you had in your life? | Yes = 1 No = 2 | [___] |
| Q42. | Have you ever suffered from a sexually transmitted infection (gonococcal disease, chlamydia or syphilis)? | Yes = 1 No = 2 | [___] |
| Q43. | Did you do manicure using common equipment? | Yes = 1 No = 2 | [___] |
| Q44. | Do you have a tattoo? | Yes = 1 No = 2 | [___] |
| Q45. | Do you have scarifications? | Yes = 1 No = 2 | [___] |
| Q46. | Do you have a piercing? | Yes = 1 No = 2 | [___] |
| Q47. | Have you ever had to do an acupuncture session? | Yes = 1 No = 2 | [___] |
| Q48 | Have you been circumcised? | Yes = 1 No = 2 | [___] |
| Q49. | Have you ever had to have dental work done? | Yes = 1 No = 2 | [___] |