PLEASE NOTE that Project ECHO® case consultations do not create or otherwise establish a provider-patient relationship between any UNM-HSC clinician and any patient whose case is being presented in a Project ECHO setting. Always use ECHO ID# when presenting a patient in clinic. Sharing patient name, initials or other identifying information violates HIPAA privacy laws.

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* 1. Clinician:

Please answer the following questions about your patient:

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

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* 3. Screening encounter date:

Date

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* 4. Age:

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* 5. Sex

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* 6. 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)

For clinical calculators (APRI, MELD, etc.), visit: http://www.hepatitisc.uw.edu/page/clinical-calculators/meld

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