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Acute Non-Viral Hepatitis Survey

The Southern Nevada Health District is working with the U.S. Food and Drug Administration (FDA) and its state partners to investigate reports of acute non-viral hepatitis in Clark County. As part of the investigation, we are attempting to obtain information which may help us to identify possible sources of illness as well as assist us in determining the extent of illness. We are administering this brief questionnaire to ask you about you and/or your household member(s) possible exposures, symptoms, and other information relating to this investigation. If you and/or your household member(s) had Acute Non-Viral Hepatitis related symptoms after consuming alkaline water, please take this survey. If multiple individuals are ill in your household, please complete a separate survey for each person. Your assistance and cooperation in this survey are appreciated.
Any information provided in this survey is considered to be confidential medical information per NRS 441A.220, and cannot be shared outside the investigation. Once again, thank you for your assistance!
1. Please provide your contact information:
2. The patient's contact information whom you are answering the questions on behalf of (if different from yours):
This question requires a valid date format of MM/DD/YYYY.
4. What is the patient's sex? 
5. Which racial group(s) does the patient belong? (Please check all that apply)
6. Is the patient Hispanic or Latino?
7. Has the patient consumed alkaline water within 6 months before their onset of symptoms?