Liver Health Screening

If you have been asked to complete a Liver Health Screening, please use this form.

Liver Health Screen

Are you worried that your liver could be damaged?
Why are you concerned?

Alcohol Consuption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *
Do you regularly take 2-3 consecutive days without alcohol?
Do you have Type 2 Diabetes?
Do you have high blood pressure?
Do you have high cholesterol?
e.g. 1.75
e.g. 60.6
Do you eat takeaways or ready meals twice or more per week?
Do you regularly eat crisps, chocolate, cakes or biscuits between meals or in the evenings?
Do you have fizzy drinks or full sugar squash/cordial?
Do you have processed foods such as sausages, pies, chips, pizza or burgers three or more times per week?
How many hours of exercise do you do each week?
Exercise is defined as any activity leaving you warm and slightly out of breath. These activities can include: brisk walking, swimming, cycling, running, playing a sport, joining a group or attending a regular exercise class.
Have you received a blood transfusion before September 1991 or a blood product (such as a clotting factor) before 1986 in the UK, or in any of the countries or regions listed below at any time?
Have you ever had medical or dental treatment or an operation in any of the countries or regions listed below?
Were you or your parents born in any of these countries or regions?
Have you ever been diagnosed with viral hepatitis?
Have you ever had a piercing or tattoo in unlicensed premises, or using tools that may have been unsterile?
Have you ever had unprotected sex (without a condom) with a partner who may have had viral hepatitis?
Have you ever shared a razor or toothbrush with anyone who may have had viral hepatitis?
Have you ever shared items to take drugs that you don’t inject into your blood, such as, rolled banknotes, straws, cups, spoons etc?
Have you ever shared needles or other equipment used for injecting drugs, steroids or other medication (such as needles, syringes, filters, spoons, water, tourniquets, cups etc)?
Do you have a family history of liver disease?
Do you take any other medication or supplements apart from what we prescribe such as over the counter/bought over the internet/from other people?