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

GP Details		
Name:	Treating Doctor.Name	
Provider Number:	Treating Doctor.Provider Number	
Practice Address:	Treating Doctor.Full Address	
Phone no:	Treating Doctor.Phone	
Fax no:	Treating 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:	HCV acquisition	
Year of chronic hepatitis C diagnosis:	Hep C Diagnosis	

Has the patient ever been diagnosed with cirrhosis?	Cirrhosis Diagnosis	
Is the patient obese (BMI ≥ 30)?	Obese Patient	
Is there a history of current or prior alcohol intake >4 std drinks/day?	Alcohol Intake	
Has the patient previously been treated for HCV?	Previous Treatment	
If yes, did the treatment contain direct acting antiviral agents?	Antiviral Agents	
Are there signs of chronic liver disease on examination?	Liver Disease	

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

APRI	Date:	APRI - D	Score:	APRI Score	
OR					
FibroScan	Date:	FibroScan - D	IQR/med(%):	IQR med - P	
	Median liver stiffness (kPa):	Liver Stiffness			

Clinical Details.Result List (Selected)

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

I have used www.hep-druginteractions.orghttp://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	«CUSTOMFIELD|537047|B|Genotype1|I will ma»	
Other direct acting antiviral	Genotype4	
List of antivirals	Antivirals	

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

GP signature:				Date: Miscellaneous.Date
 
Patient Name: Patient Demographics.Surname, Patient Demographics.First Name DOB: Patient Demographics.DOB
Version October 2017