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

mm/dd/yyyy

Site

Clinician

What is the primary question you have regarding this patient?

Age

Sex at Birth

Gender Identity

Insurance

Is patient eligible for IHS PRC?

Check if yes.

Liver Related History

Cirrhosis?

Any evidence of clinical decompensation?

Previous HCV Treatment?

Year of HCV Diagnosis

Heptocellular Carcinoma?

Other History

Medical Diagnoses

Psychiatric Diagnoses

Depression Screening (if available):

Substance Use History

Does the person have a substance use disorder?

History of Injecting Drugs?

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?

Body Mass Index

Height

Weight

BMI

Hepatitis Vaccination and Labs

Hepatitis A total or IgG antibody:

Hepatitis B surface antibody (anti-HBs):

Hepatitis B core antibody (anti-HBc):

Hepatitis B surface antigen (HBsAg):

Labs

WBC Date

mm/dd/yyyy

WBC Result

HGB Date

mm/dd/yyyy

HGB Result

HCT Date

mm/dd/yyyy

HCT Result

Platelets Date

mm/dd/yyyy

Platelets Result

Creatinine Date

mm/dd/yyyy

Creatinine Result

Protime/INR Date

mm/dd/yyyy

Protime/INR Result

Total Prot Date

mm/dd/yyyy

Total Prot Result

Albumin Date

mm/dd/yyyy

Albumin Result

Alk Phos Date

mm/dd/yyyy

Alk Phos Result

AST Date

mm/dd/yyyy

AST Result

ALT Date

mm/dd/yyyy

ALT Result

T. Bili Date

mm/dd/yyyy

T. Bili Result

Direct Bili Date (if available)

mm/dd/yyyy

Direct Bili Result

HIV Ab Date

mm/dd/yyyy

HIV Ab Result

HCV RNA Date

mm/dd/yyyy

HCV RNA Result

HCV GT Date (genotype)

mm/dd/yyyy

HCV GT Result

AFP Date (for patients with known or suspected cirrhosis)

mm/dd/yyyy

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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