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Hepatitis B

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Reporting Form*

Please use this form to report cases of Hepatitis B. All information will be kept confidential. Your cooperation will help us to better understand the epidemiology of Hepatitis B.

Patient Information:

Last Name:

First Name:

Telephone:

(123-456-7890)

Address:

City:

Zip:

Sex:

Male: Female:

Birthdate:

Month:

Day:

Year: 19

E-mail:

Date diagnosed:

(mm/dd/yy)

Risk Factors:

Please check all that apply:

	Have had more than 4 sexual partners in the last year.
	Are a male who has had homosexual relations in the past year.
	Have used IV drugs in the past.
	Have had sexual relations with an HBV infected partner.
	Work in a hospital or health care setting.
	Other. Please specify

*Please note that this reporting form was made solely for the purposes of the class and is not actually linked to any type of database. Please do not report any information with this form.

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©2001
Disclaimer-Please note that this website was made for the purposes of a class.
For comments or questions, e-mail me at jasers24@aol.com.