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|Concomitant Medical Diagnosis |Current Medications |

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|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 | |

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|Staging of Liver Disease |

|Test Performed |Date |Findings/Results |

|Liver Biopsy | | |

|Ultrasound | | |

|HCV Fibrosure Assay | | |

|Transient Elastography | | |

Other Information______________________________________________________________________

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