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 | [___] |