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Hepatitis Checklist and Referral Form Contact details: GSTT KCH Other Address Phone Fax Email Referral Date Referring Clinician Practice Details ~[Today...] ~[Free Text:Referring Clinician?] ~[Surgery Address Line 1] ~[Surgery Address Line 2] ~[Surgery Address Line 3] ~[Surgery Address Line 4] ~[Surgery Address Line 5] ~[Surgery Tel No.] Patient Name DOB ~[Forename] ~[Surname] ~[Date Of Birth] Patient Address ~[Patient Address Block] Patient Tel Mobile NHS Number Hospital Number ~[Telephone Number] ~[Mobile]~[Mobile Number] ~[NHS Number] ~[Hospital Number] History How long has this patient been registered at your practice? Date exposure took place (if known)? How was the patient exposed/method of transmission (if known)? Has this patient been treated for hepatitis B or C in the past? Which centre? Have contacts/family members been informed? Advice given to patient regarding safe sex? Alcohol history (units/week): FAST questionnaire score: Smoking history: Final March 2013 Please complete hepatitis B+C serology for all patients and document results fully below Decision Matrix for Hep B (NICE) Hepatitis (Please tick) HBV REFER / INFORM SPECIALIST SERVICES IF: Surface antigen test positive* All individuals with HBV SAg +ve should be referred (the term ‘carrier’ is misleading) eAntigen positive PRIOR TO REFERRAL, PLEASE COMPLETE AND DOCUMENT/ATTACH Liver function tests, including AST and GGT DNA titre AFP HIV test Ultrasound *Individuals with HBV s Ag –ve & cAb +ve alone have cleared HBV spontaneously, repeat test to exclude false positive Final March 2013 REFER / INFORM SPECIALIST SERVICES IF: HCV HCV RNA positive** include level: ____________ PRIOR TO REFERRAL, PLEASE COMPLETE AND DOCUMENT BELOW Genotype Liver function tests, including AST and GGT AFP HIV test Ultrasound **15-20% of patients will clear HCV (HCV RNA negative) – these individuals do not have chronic HCV and so do not need referral PLEASE perform HIV testing for all patients prior to referral. If not possible please DISCUSS need for HIV test Have patient’s family members and close contacts been screened and vaccinated? ( YES/NO/NOT TESTED)] GP comments (including any other relevant information): ~[Free Text:Any other Comments including Relevant History?] Diabetes (year of diagnosis and recent HbA1c) Weight / BMI ~[ReadCode:22A~1Y~~R~Date|Free Text~1]/~[ReadCode:22K~1Y~~R~Date|Free Text~1] Blood pressure ~[Blood Pressure:1] Medications ~[Medication] Allergies ~[Allergies] Final March 2013