Liver Disease Screening Questionnaire
Please answer the following questions to help screen for risk factors and symptoms related to liver disease.
Year of Birth
*
Gender
*
Male
Female
Prefer not to say
Other
How often do you consume alcoholic beverages?
*
Never
Occasionally (1-2 times/month)
Weekly (1-2 times/week)
Frequently (3+ times/week)
Have you ever been diagnosed with any of the following conditions?
*
Hepatitis B
Hepatitis C
Fatty liver disease
Cirrhosis
None of the above
Do you have a family history of liver disease?
*
Yes
No
Not sure
Do you currently take any prescription or over-the-counter medications regularly?
*
Yes
No
In the last 6 months, have you experienced any of the following symptoms?
*
Unexplained fatigue
Yellowing of skin or eyes (jaundice)
Abdominal swelling
Easy bruising or bleeding
None of the above
How would you rate your current overall health?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Have you ever had abnormal liver function tests?
*
Yes
No
Not sure
Please list any other relevant health information or concerns (optional)
Submit
Should be Empty: