GRAMPIANS REMOTE CONSULTATION FOR INITIATION OF HEPATITIS C TREATMENT
Fax to Ballarat Health Services Gastroenterology and Liver Clinic: 03 53204097
Attention: Dr. Al-Ansari
Referral date: <<Miscellaneous:Date (long)>>

GP Details		
Name:	<<Doctor:Name>>	
Provider Number:	<<Doctor:Provider Number>>	
Practice Address:	<<Doctor:Full Address>>	
Phone no:	<<Doctor:Phone>>	
Fax no:	<<Doctor:Fax>>	

Patient Details		
Name:	<<Patient Demographics:Full Name>>	
DOB:	<<Patient Demographics:DOB>>	
Address:	<<Patient Demographics:Full Address>>	

Please refer patients directly to the Ballarat Health Services Gastroenterology and Liver Clinic for specialist assessment if:
•	History, examination or investigations suggestive of cirrhosis (i.e. liver stiffness is > 12.5 kPa or APRI >1.0) or;
•	Previously treated with regimens containing direct acting antiviral agents or;
•	Concomitant medications not listed on the Liverpool website or drug interactions are such that assistance is required or;
•	Patient has received amiodarone in the last 3 months or;
•	Pregnant or breastfeeding female.

Likely year of HCV acquisition:	<<Likely year of HCV acquisition>>	
Year of chronic hepatitis C diagnosis:	<<Year of chronic hepatitis C diagnosis>>	

Has the patient ever been diagnosed with cirrhosis?	<<Has the patient ever been diagnosed with cirrhosis>>	
Is the patient obese (BMI ≥ 30)?	<<Is the patient obese (BMI 30+)>>	
Is there a history of current or prior alcohol intake >4 std drinks/day?	<<Current or prior alcohol intake 4+ std drinks/day>>	
Has the patient previously been treated for HCV?	<<Previously been treated for HCV>>	
If yes, did the treatment contain direct acting antiviral agents?	<<Did treatment contain direct acting antiviral agents>>	
Are there signs of chronic liver disease on examination?	<<Signs of chronic liver disease on examination>>	

	Date	Result	
HCV genotype (must be within the last 12 months)	<<HCV genotype - DATE>>	<<HCV genotype - RESULT>>	
HCV RNA level	<<HCV RNA level - DATE>>	<<HCV RNA level - RESULT>>	
HIV serology	<<HIV serology - DATE>>	<<HIV serology - RESULT>>	
HBV sAg	<<HBV sAg - DATE>>	<<HBV sAg - RESULT>>	
HBV cAb	<<HBV cAb - DATE>>	<<HBV cAb - RESULT>>	
HBV sAb	<<HBV sAb - DATE>>	<<HBV sAb - RESULT>>	
Haemoglobin	<<Haemoglobin - DATE>>	<<Haemoglobin - RESULT>>	
Platelets	<<Platelets - DATE>>	<<Platelets - RESULT>>	
Albumin	<<Albumin - DATE>>	<<Albumin - RESULT>>	
AST and AST upper limit of normal	<<AST and AST upper limit of normal - DATE>>	<<AST and AST upper limit of normal - RESULT>>	
ALT	<<ALT - DATE>>	<<ALT - RESULT>>	
Bilirubin	<<Bilirubin - DATE>>	<<Bilirubin - RESULT>>	
eGFR	<<eGFR - DATE>>	<<eGFR - RESULT>>	
INR	<<INR - DATE>>	<<INR - RESULT>>	
B-HCG if female	<<B-HCG if female - DATE>>	<<B-HCG if female - RESULT>>	

APRI	Date:	<<APRI date>>	Score:	<<APRI Score>>	
OR					
FibroScan	Date:	<<FibroScan date>>	IQR/med(%):	<<IQR/med(%)>>	
	Median liver stiffness (kPa):	<<Median liver stiffness (kPa)>>			

<<Summary:Investigation Results (Selected)>>

The management of this patient will be according to the Australian Recommendations for the Management of HCV infection consensus statement 2017: <<Management according to HCV infection consenus>> 

I have used www.hep-druginteractions.org to check and will manage interactions between the patient's current medications (including over the counter and herbal preparations) and:

Sofosbuvir/ledipasvir for genotype 1,2,3,4,5 or 6	<<Sofosbuvir/ledipasvir for genotypes 1,2,3,4,5 or 6>>	
Other direct acting antiviral 	<<I will manage interactions with directacting antivirals>>	
List of antivirals	<<Please list antivirals>>	

GP declaration: I declare all of the information provided above is true and correct

GP signature:				Date: <<Miscellaneous:Date (short)>>

Patient Name: <<Patient Demographics:Surname>>, <<Patient Demographics:First Name>> DOB: <<Patient Demographics:DOB>>
Version October 2017