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Requested
Illustration:
1. LIST DATE AND RESULTS OF THE CLIENT'S TWO
MOST RECENT LIVER FUNCTION TESTS:
AST/SGOT RESULT
DATE
AST/SGOT RESULT
DATE
ALT/SGOT RESULT
DATE
ALT/SGOT RESULT
DATE
GGTP RESULT
DATE
GGTP RESULT
DATE
ALK PHOS RESULT
DATE
ALK PHOS RESULT
DATE
BILIRUBIN RESULT
DATE
BILIRUBIN RESULT
DATE
2. CHECK TYPE, THEN LIST DATE AND RESULTS OF RECENT HEPATITIS SCREENING:
A DATE
NEGATIVE,
POSITIVE
B DATE
NEGATIVE,
POSITIVE
C DATE
NEGATIVE,
POSITIVE
3.
HAS THE CLIENT HAD A LIVER BIOPSY?
IF YES, DETAIL DATE AND RESULTS:
4. HAS THE CLIENT EVER BEEN DIAGNOSED WITH:
FATTY LIVER
YES, CHECK TYPE, THEN DETAIL:
ACUTE,
CHRONIC ACTIVE,
CHRONIC PERSISTENT
DETAILS:
5. DOES THE CLIENT CURRENTLY CONSUME ANY TYPE OF ALCOHOLIC BEVERAGE?
IF YES, HOW OFTEN AND IN WHAT AMOUNT:
IF NO, DATE OF LAST DRINK:
Month
Year
6.
DATE OF CLIENT'S LAST VISIT TO A PHYSICIAN:
7. LIST THE LAST CHOLESTEROL READING, IF KNOWN:
HDL RATIO
8. LIST THE LAST BLOOD PRESSURE READING, IF KNOW:
SYSTOLIC
DIASTOLIC
9.
CLIENT'S OCCUPATION
10. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL
11. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
IF YES, PLEASE DETAIL
12.
PLEASE LIST ANY OTHER ILLNESSES OR
IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:
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