Q16.

Have you ever had a sexually transmitted infection (gonorrhea, chlamydia or syphilis)?

Yes = 1

No = 2

[___]

Q17.

Have you had sex with people of the same sex as you?

Yes = 1

No = 2

[___]

Q18.

Do you have a tattoo?

Yes = 1

No = 2

[___]

Q19.

Have you ever had any scarring

Yes = 1

No = 2

[___]

Q20.

Was your circumcision medicalized

Yes = 1

No = 2

Not applicable = 3

[___]

III. MEDICAL HISTORY

Q21.

Sickle cell disease

Yes = 1

No = 2

[___]

Q22.

Hemophilia

Yes = 1

No = 2

[___]

Q23.

Dialysis

Yes = 1

No = 2

[___]

Q24.

Transfusion

Yes = 1

No = 2

[___]

Q25.

Diabetes

Yes = 1

No = 2

[___]

Q26.

Surgical history

Yes = 1

No = 2

[___]

IV. CLINICAL DATA RELATED TO HEPATITIS B + DELTA

Q27.

Reason for consultation

Q28.

Circumstances of HBV discovery

Blood donation = 1

Screening = 2

Digestive disorders = 3

Asthenia = 4

Cytolysis = 5

[___]

Q29.

Asymptomatic

Yes = 1

No = 2

[___]

Q30.

Jaundice

Yes = 1

No = 2

[___]

Q31.

Cirrhosis

Yes = 1

No = 2

[___]

Q32.

Hepatocellular carcinoma

Yes = 1

No = 2

[___]

Q33.

Were you ever hospitalized once?

Yes = 1

No = 2

[___]

Q34.

If so, for what reasons?

Q35.

Have you received injections from anyone other than a health worker?

Yes = 1

No = 2

[___]