Appendix A. Online Risk Assessment Tool - AHRQ National ...

Immunizations (continued)# Question Prereq Sub-Question Options Script(s) Programming NotesPlease answer "Yes,""No," or "Don't know" to"No" or"Don't know"to Hep BvaccinequestionHave you ever livedwith someone whoHep B at risk script - haveVPA hold paper with list ofrisks (if more than one is2 the following questions: above has Hepatitis B? Yesselected)2 Please answer "Yes," "No," or "Don't know" to the following questions: "No" or "Don't know" to Hep B vaccine question above Have you ever lived with someone who has Hepatitis B?No2 Please answer "Yes," "No," or "Don't know" to the following questions: "No" or "Don't know" to Hep B vaccine question above Have you ever lived with someone who has Hepatitis B?2aIf "Male" or"Both" toQuestion 3 inHealthPromotion2a If "Male" or "Both" to Question 3 in Health Promotion Does your partner have Hepatitis B?No2a If "Male" or "Both" to Question 3 in Health Promotion Does your partner have Hepatitis B?2b"Yes" to 1 ofHealthPromotionDoes your partnerhave Hepatitis B?Have you had sexwith more than oneperson during thepast 6 months?2b "Yes" to 1 of Health Promotion Have you had sex with more than one person during the past 6 months?No2b "Yes" to 1 of Health Promotion Have you had sex with more than one person during the past 6 months?2c2c Are you being treated with hemodialysis?No2c2eAre you being treatedwith hemodialysis?Are you being treated with hemodialysis?Have you everworked or do you livein an institution for thedevelopmentallydisabled?2e Have you ever worked or do you live in an institution for the developmentally disabled?NoHave you traveled toHaiti, DominicanRepublic, Africa,Southeast Asia, theMiddle East (exceptIsrael), South PacificIslands, West PacificIslands, or theAmazon River Basinin the last year?13Don'tknowYesDon'tknowYesDon'tknowYesDon'tknowYesat risk forSTIat risk forSTIat risk forSTIat risk forSTIHep B atriskHep B atriskHep B at risk script - haveVPA hold paper with list ofrisks (if more than one isselected)Hep B at risk script - haveVPA hold paper with list ofrisks (if more than one isselected)Hep B at risk script - haveVPA hold paper with list ofrisks (if more than one isselected)Hep B at risk script - haveVPA hold paper with list ofrisks (if more than one isselected)Hep B at risk script - haveVPA hold paper with list ofrisks (if more than one isselected)Hep B at risk script - haveVPA hold paper with list ofrisks (if more than one isselected)Hep B at risk script - haveVPA hold paper with list ofrisks (if more than one isselected)Hep B at risk script - haveVPA hold paper with list ofrisks (if more than one isselected)Hep B at risk script - haveVPA hold paper with list ofrisks (if more than one isselected)2gYesHave you traveled to Haiti, Dominican Republic, Africa, Southeast Asia, the Middle East (except No2gIsrael), South Pacific Islands, West Pacific Islands, or the Amazon River Basin in the last year?Source: Adapted from Jack BW, Culpepper L, Babcock J, Kogan MD, Weismiller D. Addressing Preconception Risks Identifiedat the Time of a Negative Pregnancy Test. A Randomized Trial. J Fam Pract. 1998;47(1)33-38. Reviewed by Dean V. Coonrod,MD, MPH; Richard Long, MD; Shanna N. Cox, MSPH.