Patient Information

Last Name:

First Name:

Gender: Male  Female

Date of Birth:

Permanent Address:

Diagnosis Date:

Physician Information

Name of Diagnosing Physician:  

Telephone Number of Physician:

Laboratory Confirmation Tests

Serologic: positive  negative

PCR: positive  negative

Liver Enzymes: elevated  normal

Risk Factors (select all that apply)

IV Drug User

Blood Transfusion

More than 5 sexual partners in lifetime

Occupational Exposure

Other (If selected, describe)