** Denotes required information

Liver Enrollment Form

Site Code: **       Accrual Number: **       Initials: **
Patient Key:
For a list of site codes, click here. If no middle initial, use 'X'. Patient Key will be of the form XXXXXX-000-XXX

General Information

Pre-Transplant Diagnosis:
Other Pre-Transplant Diagnoses:
Liver Graft Type:

Clinical/Laboratory Findings

Blood Pressure:
mmHg Systolic /    mmHg Diastolic
AST:
ALT:
GGT:
Bilirubin Total:

mg/dL
umol/L
Bilirubin Direct:

mg/dL
umol/L
INR:
PLT:
103/L
Creat:

mg/dL
umol/L

Biopsies

Number of Biopsies Performed:
Note: complete a biopsy report for EACH biopsy