| PATIENT DETAILS |
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| Patient Name |
Patient Demographics.Full Name
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UR No (if Known):
UR No (if known)
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| Patient's Date of Birth: |
Patient Demographics.DOB
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Gender:
Patient Demographics.Gender
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| Patient's Address: |
Patient Demographics.Full Address
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Patient Demographics.Suburb
Patient Demographics.Postcode
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| Patient's Phone: |
Home:
Patient Demographics.Phone (Home)
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Mobile:
Patient Demographics.Phone (Mobile)
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| Liver Biopsy
Liver biopsy perform
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Liver Function
Liver function perf
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| Date:
Date of Liver Biopsy
Fibrosis Stage:
Fibrosis Stage
Inflammatory Grade:
Inflammatory Grade
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Date:
Date of LFT
Total Protein:
Total Protein Result
g/L Albumin:
Albumin Result
g/L
ALT:
ALT Result
g/L Bilirubin:
Bilrubin Result
μmol/L
GGT:
GGT Result
U/L ALP:
ALP Result
U/L
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| Previous FibroScan®:
Previous FibroScan
Number of scans:
No of Fibroscans
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Haematology |
| Date:
Date most recent FS
Result:
Fibroscan Result
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Haemoglobin:
Haemoglobin Result
g/L Platelets:
Platelets Result
x 109 /L
INR:
INR Result
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| Comorbidities |
Clinical Assessment of Liver Scanning |
| ¨ Hepatitis B ¨ HIV ¨ Hepatitis C ¨ NASH
¨ Alcohol ¨ IDDM/NIDDM
¨ Cystic Fibrosis ¨ Other
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Liver Scanning Ass
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| Fasting >2hrs:
Fasting >2 hours
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| Clinical Notes:
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| Referred By: |
Treating Doctor.Name
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Report Copies To: |
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| Referring Dr Address: |
Treating Doctor.Full Address
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| Referring Dr Contacts: |
Phone:
Treating Doctor.Phone
Fax:
Treating Doctor.Fax
Email:
Treating Doctor.E-mail
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| Signature: |
Date:
Miscellaneous.Date
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Provider No:
Treating Doctor.Provider Number
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Practice Location:
Practice.Address
Country of Birth:
Country of Birth
Identify as ATSI:
Identify as ATSI
Height:
Height (m)
Weight:
Weight (kg)
BMI:
BMI
Risk Factors for Hepatitis
IDU - Current (<6 months): ¨ Yes ¨ No
IDU - Past (>6 months): ¨ Yes ¨ No
Vertical/ Early Horizontal: ¨ Yes ¨ No
Sexual - MSM: ¨ Yes ¨ No
Sexual - Non MSM: ¨ Yes ¨ No
Other (specify):
Alcohol:
Clinical Details.Alcohol (Summary)
Features of Decompensation
Ascites: ¨ Yes ¨ No
Encephalopathy: ¨ Yes ¨ No
| PLEASE NOTE: FIBROSCAN® IS AN INVESTIGATIONAL DEVICE AND DOES NOT HAVE PROVEN EQUIVALENCE TO LIVER BIOPSY IN THE ASSESSMENT OF HEPATIC FIBROSIS. |
| FibroScan® is an ultrasound device providing an estimation of hepatic fibrosis. The results of FibroScan® need to be interpreted in conjunction with the patient's clinical circumstances. FibroScan® should be repeated when results are discordant with clinical context and consideration for liver biopsy should be given when discordance is explained. Please note that FibroScan® is an investigational device and does not have provene quivalence to liver biopsy in the assessment of hepatic fibrosis. FibroScan® does not replace conventional liver ultrasound and is not intended for the investigation or exclusion of liver lesions or biliary tract disease.
There is no requirement to fast or alter medication use prior to undergoing FibroScan®. FibroScan® assessment may not be possible in up to 1/4 of patients with a BMI > 30 kg/m2 and alternative investigations may be appropriate.
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