Get me the following info and I can get you an answer:
Client ______________________________________________ Age/DOB _________________ Sex ______________________
If your client has had hepatitis C, please answer the following:
1. Please list date of diagnosis: __________________________________________________ ___________________________
2. Please give the date and results of the most recent liver enzyme tests:
A) AST/SGOT __________________________________________________ ___________________________________
B) ALT/SGPT __________________________________________________ ____________________________________
C) GGTP __________________________________________________ ________________________________________
3. Is your client on any medications?
n
yes, please give details __________________________________________________ _________________________
n
no
4. Does your client drink alcohol?
n
yes, please note amount and frequency __________________________________________________ ___________
n
no
5. Please check if any of the following studies have been completed:
A) liver ultrasound or CT scan n normal n abnormal
B) liver biopsy n normal n abnormal
C) viral load, i.e. PCR, HCV-DNA __________________________________________________ __________________
6. Has your client been diagnosed with any of the following:
n
chronic hepatitis
n
cirrhosis
7. Has your client been treated with interferon or other anti-viral drugs?
n
yes, please give details __________________________________________________ _______________________
n
no
8. Does your client have any other major health problems (ex: cancer, etc.)?
n
yes, please give details __________________________________________________ _______________________
n
no
Hepatitis C, Underwriting
Linear Mode
