** Denotes required information
Liver Follow-Up 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
Today's Date:
(mm/dd/yyyy)
(mm/dd/yyyy)
Follow-Up Year:
(yyyy)
(yyyy)
All Other Current Medications:
Current Subject Status:
(mm/dd/yyyy)
(mm/dd/yyyy)
Current Graft Status:
Since Enrollment/Last Update
Number of Rejection Episodes:
Graft Loss:
No Yes
No Yes
Retransplantation:
(mm/dd/yyyy)
(mm/dd/yyyy)
Resumed IS:
(mm/dd/yyyy)
(mm/dd/yyyy)
Latest Clinical/Laboratory Findings
Height:
cm in
cm in
Weight:
kg lb
kg lb
Blood Pressure:
mmHg Systolic / mmHg Diastolic
mmHg Systolic / mmHg Diastolic
AST:
U/L
U/L
ALT:
U/L
U/L
GGT:
U/L
U/L
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 Since Enrollment/Last Update:
Note: complete a biopsy report for EACH biopsy
Note: complete a biopsy report for EACH biopsy