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-265430115965Primary Care Consultation Request -Initiation of Hepatitis C Treatment in Victoria 00Primary Care Consultation Request -Initiation of Hepatitis C Treatment in Victoria Note: All fields below are mandatoryATTENTION OF:Hospital: Department (Gastroenterology or ID):Dr (if known):Fax: Email:GP DETAILSGP name:Provider no:GP address:GP contacts: Phone: Fax:Email:PATIENT DETAILSPatient Name UR no (if known):Patient Date of BirthGender: Male FORMCHECKBOX Female FORMCHECKBOX Pregnant or nursing female:Yes FORMCHECKBOX * No FORMCHECKBOX N/A FORMCHECKBOX FibroScan? Date: ____/____/_____ Median liver stiffness (kPa): _______ Is it >12.5:Yes FORMCHECKBOX * No FORMCHECKBOX IQR/med (%): ________ APRI scoreOnline APRI CalculatorDate: ____/____/_____ Result: _________ Is it >1.0:Yes FORMCHECKBOX * No FORMCHECKBOX *If ANY apply, please refer to a specialist for clinical reviewHepatitis C HistoryIntercurrent conditionsLikely year of acquisition:Diabetes:Yes FORMCHECKBOX No FORMCHECKBOX Year of chronic hepatitis C diagnosis: Obesity (BMI>30):Yes FORMCHECKBOX No FORMCHECKBOX Known cirrhosis:Yes FORMCHECKBOX * No FORMCHECKBOX Immunosuppressed:Yes FORMCHECKBOX No FORMCHECKBOX Hepatic decompensation (ascites, encephalopathy, variceal bleeding):Yes FORMCHECKBOX * No FORMCHECKBOX Hepatitis B:Yes FORMCHECKBOX * No FORMCHECKBOX Any previous treatment with Direct Acting Antivirals for HCV:Yes FORMCHECKBOX No FORMCHECKBOX HIV:Yes FORMCHECKBOX * No FORMCHECKBOX *If ANY apply, please refer to a specialist for in person clinical reviewAlcohol >40g / day:Yes FORMCHECKBOX No FORMCHECKBOX LABS (OR ATTACH COPY OF RESULTS)TestDateResultTestDateResultHCV genotypeINRViral loadCreatinineALTeGFRASTHbTotal bilirubinPlateletsAlbuminβ HCGDRUG INTERACTIONS AND COUNSELLINGI have entered current medication (prescription and over-the-counter) and proposed treatment regimen according to genotype into and assessed outputs. Recommend printing and attaching the outputs.NB: Current GP practice software is NOT sufficient for assessing these potential drug interactions. Complementary and alternative medicines should already be ceased and therefore not entered. Yes FORMCHECKBOX No FORMCHECKBOX On no medication FORMCHECKBOX Amiodarone at any time in last 3 months:Yes FORMCHECKBOX No FORMCHECKBOX 2590165711200018656307429500*If hep-drug interactions chart RED or AMBER please await specialist responseCease ALL non-traditional (complementary and alternative) medicines during treatment:Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMCHECKBOX Contraception education given (males and females):Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMCHECKBOX Management of this patient will be according to the Australian Recommendations for the Management of HCV infection consensus statement 2016Yes FORMCHECKBOX No FORMCHECKBOX HCV INTENDED TREATMENT REGIMEN (for patients not requiring referral)RegimenGenotypeDurationPlease tickSofosbuvir + ledipasvir18 weeks FORMCHECKBOX 112 weeks FORMCHECKBOX Sofosbuvir + daclatasvir112 weeks FORMCHECKBOX 312 weeks FORMCHECKBOX Sofosbuvir + ribavirin212 weeks FORMCHECKBOX Paritaprevir + ritonavir + ombitasvir + dasabuvir112 weeks FORMCHECKBOX Paritaprevir + ritonavir + ombitasvir + dasabuvir + ribavirin112 weeks FORMCHECKBOX Monitoring of patients on treatment – see Australian Consensus Statement, HealthPathways or Hepatitis VictoriaAlcohol and other drugs (AOD) support – see DirectLine, Victorian AOD intake and assessments numbers and DHHSDECLARATION OF PRIMARY HEALTH CARE PROVIDER:I declare all of the above information provided is complete, true and correct.Name:Signature:Date:DECLARATION OF HCV SPECIALIST:I agree / do not agree with the decision to treat this person based on the information provided above.Name:Signature:Date:Additional comments (e.g. incomplete information provided/ requires referral to clinic): ................
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