Infectious Disease Case Form- USET

Infectious Disease Case Form- USET

To submit a case, fill out the form below with the applicable information:

If you have any questions about this case form,

please contact Bryan Hendrix at bhendrix@usetinc.org

Your Name*

Contact Email*

Phone

Presentation Date

Site

Clinician

What is the primary question you have regarding this patient?

Age

Sex at Birth

Select or enter value

Gender Identity

Insurance

Select or enter value

If other Insurance, please list here:

Is patient eligible for IHS PRC?

Check if yes.

Liver Related History

Cirrhosis?

Select or enter value

Any evidence of clinical decompensation?

Select or enter value

Previous HCV Treatment?

Select or enter value

Year of HCV Diagnosis

Heptocellular Carcinoma?

Select or enter value

Other History

Medical Diagnoses

Select or enter value

If other relevant medical diagnoses, please list here:

Psychiatric Diagnoses

Select or enter value

If other relevant psychiatric diagnoses, please list here:

Depression Screening (if available):

Select or enter value

If other depression screening, please list here:

Substance Use History

Does the person have a substance use disorder?

Select or enter value

History of Injecting Drugs?

Select or enter value

Current Medications

Medication Name, Dosage, and Frequency (please include only one medication per line)

Current Method of Birth Control:

If oral contraceptive, does it contain ethinyl estradiol?

Select or enter value

Body Mass Index

Height

Weight

BMI

Hepatitis Vaccination and Labs

Hepatitis A total or IgG antibody:

Select or enter value

Hepatitis B surface antibody (anti-HBs):

Select or enter value

Hepatitis B core antibody (anti-HBc):

Select or enter value

Hepatitis B surface antigen (HBsAg):

Select or enter value

Labs

WBC Date

WBC Result

HGB Date

HGB Result

HCT Date

HCT Result

Platelets Date

Platelets Result

Creatinine Date

Creatinine Result

Protime/INR Date

Protime/INR Result

Total Prot Date

Total Prot Result

Albumin Date

Albumin Result

Alk Phos Date

Alk Phos Result

AST Date

AST Result

ALT Date

ALT Result

T. Bili Date

T. Bili Result

Direct Bili Date (if available)

Direct Bili Result

HIV Ab Date

HIV Ab Result

HCV RNA Date

HCV RNA Result

HCV GT Date (genotype)

HCV GT Result

AFP Date (for patients with known or suspected cirrhosis)

AFP Result

Fibrosis Score

APRI

FIB-4

FIBROTEST

FIBROSCAN

MELD (For cirrhotic patients only)

Child-Pugh (For cirrhotic patients only)

Imaging

Please list any imaging or transient elastography results, if applicable (e.g. ultrasound, fibroscan, etc.):

Other Information

Please list any additional pertinent information

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