** 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
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
mmHg Systolic / mmHg Diastolic
AST:
ALT:
GGT:
Bilirubin Total:
mg/dL
umol/L
mg/dL
umol/L
Bilirubin Direct:
mg/dL
umol/L
mg/dL
umol/L
INR:
PLT:
103/L
103/L
Creat:
mg/dL
umol/L
mg/dL
umol/L
Biopsies
Number of Biopsies Performed:
Note: complete a biopsy report for EACH biopsy
Note: complete a biopsy report for EACH biopsy