** 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

General Information

Today's Date:

(mm/dd/yyyy)
Follow-Up Year:

(yyyy)
Current Medications:

+ Show All
All Other Current Medications:
Current Subject Status:


(mm/dd/yyyy)
Current Graft Status:

Since Enrollment/Last Update

Number of Rejection Episodes:
Graft Loss:
No    Yes
Retransplantation:


(mm/dd/yyyy)
Resumed IS:


(mm/dd/yyyy)

Latest Clinical/Laboratory Findings

Height:

cm in
Weight:

kg lb
Blood Pressure:
mmHg Systolic /    mmHg Diastolic
AST:
U/L
ALT:
U/L
GGT:
U/L
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 Since Enrollment/Last Update:
Note: complete a biopsy report for EACH biopsy