Viral Hepatitis ECHO Case Presentation Form Survey

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* 6. Race and ethnicity information is collected to ensure treatment equity and assist in our attempts to address racial disparities across the state of Minnesota.

Ethnicity: Hispanic or Latino

Yes

Unknown

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* 7. Race (Check all that apply)

White or Caucasian

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

Unknown

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* 8. Is the patient African-born?

Yes

Unsure

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* 9. Insurance

None

Medicare

Medicaid, MCO

Commercial Health Insurance

Other

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* 10. Is the patient currently pregnant?

Yes

Unknown

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* 11. This patient has the following conditions:

HCV

HBV

Neither

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* 12. Suspected route of HCV transmission (Check all that apply)

Current or former injection/intranasal drug use (even once)

Blood products received prior to 1992

Solid organ transplant before 1992

Needlestick injury in healthcare setting

Perinatal transmission

MSM

Sharing personal items, such as razors or tooth brushes with a person with HCV infection

Non-professional tattoo

Unknown

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* 13. Suspected route of HBV transmission (Check all that apply)

Current or former injection/intranasal drug use (even once)

Blood products received prior to 1992

Solid organ transplant before 1992

Needlestick injury in healthcare setting

Perinatal transmission

MSM

Sharing personal items, such as razors or tooth brushes with a person with HCV infection

Non-professional tattoo

Unknown

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* 14. If the patient has HCV, please answer the following questions:

Date of positive HCV ab test

Date of prior negative HCV ab test

Date of positive HCV PCR

Genotype

Staging information

Previous HCV treatment

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* 15. If the patient has HBV, please answer the following questions:

Date of positive HBsAg

Date of HBV PCR

HBeAg positive/negative

HBeAb positive/negative

Has the patient received prior treatment?

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* 16. Does the patient have:

Alcoholic liver disease

NASH

Hepatocellular Carcinoma

Prior episode of bleeding esophageal varices

Other Liver disease

Please indicate year of diagnosis for any disease checked above:

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* 17. Does the patient have cirrhosis?

Evidence of decompensation

Ascites

Hepatic encephalopathy

Unknown

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* 18. Does the patient have fibrosis staging?

Yes

Results:

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* 19. Other medical diagnosis (Check all that apply)

HIV

Auto Immune Disease

Brain Injury

Cancer

CHF

Coronary Artery Disease

Cryoglobulinemia

Diabetes Mellitus

Hypertension

Reflux disease

Chronic Kidney Disease

Hepatitis Delta (HDV)

Other (please specify)

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* 20. Hepatitis vaccinations (REMINDER: Patients with hepatitis C need to be vaccinated for both hepatitis A and B)

Patient has a history of hepatitis A vaccination or reactive hepatitis A total/IgG lab

Patient has a history of hepatitis B vaccination or reactive hepatitis B total/IgG lab

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* 21. Psychiatric diagnosis

Depression

Anxiety

Mania/Hypomania

None

Other (please specify)

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* 22. Does the patient have a family history of:

HBV

HCV

Neither

Both

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* 23. Is the patient currently drinking alcohol?

Yes

If yes, how many drinks per day?

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* 24. Does the patient have a previous history of alcohol abuse?

Yes

Unsure

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* 25. Does the patient have a previous history of drug abuse?

Oral drug use

IV drug use

Intranasal drug use

Inhalation

Patient is on an opioid replacement drug

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* 26. If the patient has a previous history of alcohol or other drug use, when was the date of their last drink or drug use?

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* 27. Current medications, herbal supplements and OTC medications

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* 28. Body mass index

Weight:

BMI:

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* 29. Lab results (Please be prepared to provide dates of lab tests when you present your case)

WBC

HGB

Plt

Creatinine

eGFR

Albumin

ALT

AST

Alk Phos

T. Bili

Direct Bili

HBsAg

HBsAb

HBcAb total

HIV Ab

HCV genotype

HCV Viral Load

INR

AFP

Glucose

A1C

CD4 count

HIV RNA

FIB4

Liver imaging test

MELD if cirrhotic

HAV IgG

Other:

HBV DNA

HBeAg

HBeAb

HDV Ab

Viral Hepatitis ECHO Case Presentation Form

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* 1. Clinician:

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* 2. What guidance or clinical question do you need addressed?

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* 3. Screening encounter date:

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* 4. Age:

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* 5. Sex

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* 6. Race and ethnicity information is collected to ensure treatment equity and assist in our attempts to address racial disparities across the state of Minnesota.Ethnicity: Hispanic or Latino

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* 7. Race (Check all that apply)

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* 8. Is the patient African-born?

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* 9. Insurance

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* 10. Is the patient currently pregnant?

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* 11. This patient has the following conditions:

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* 12. Suspected route of HCV transmission (Check all that apply)

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* 13. Suspected route of HBV transmission (Check all that apply)

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* 14. If the patient has HCV, please answer the following questions:

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* 15. If the patient has HBV, please answer the following questions:

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* 16. Does the patient have:

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* 17. Does the patient have cirrhosis?

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* 18. Does the patient have fibrosis staging?

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* 19. Other medical diagnosis (Check all that apply)

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* 20. Hepatitis vaccinations (REMINDER: Patients with hepatitis C need to be vaccinated for both hepatitis A and B)

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* 21. Psychiatric diagnosis

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* 22. Does the patient have a family history of:

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* 23. Is the patient currently drinking alcohol?

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* 24. Does the patient have a previous history of alcohol abuse?

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* 25. Does the patient have a previous history of drug abuse?

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* 26. If the patient has a previous history of alcohol or other drug use, when was the date of their last drink or drug use?

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* 27. Current medications, herbal supplements and OTC medications

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* 28. Body mass index

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* 29. Lab results (Please be prepared to provide dates of lab tests when you present your case)

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* 6. Race and ethnicity information is collected to ensure treatment equity and assist in our attempts to address racial disparities across the state of Minnesota.

Ethnicity: Hispanic or Latino