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|Concomitant Medical Diagnosis |Current Medications |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
|Treatment Naïve: ( Yes ( No |
|Treatment experienced/specify regimen |
|Requested Regimen: |
|Health Maintenance |
|Smoking | |
|Use of Alcohol/Amount | |
|Substance Use | |
|Mental Health Assessment | |
|Pregnancy/Contraception | |
|Laboratory Tests and date tested |
|HCV Genotype | |ALT | |Creatinine | |
|HCV Quantitative RNA | | | | | |
| | |AST | |Platelet Count | |
|HIV Antibody | |Total Bilirubin | |Hemoglobin | |
| |
|Staging of Liver Disease |
|Test Performed |Date |Findings/Results |
|Liver Biopsy | | |
|Ultrasound | | |
|HCV Fibrosure Assay | | |
|Transient Elastography | | |
Other Information______________________________________________________________________
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