REACH-C REACH-C CHECKLISTDate of request* (dd/mm/yyyy)Patient Initials*E.g. Smith, John -> SM-JOPRESCRIBER INFORMATIONDoctor Name:*Prescriber number:*Postcode of practice location:*Doctor phone number (mobile):Doctor phone number (surgery):Doctor email:* PATIENT DEMOGRAPHICSDate of birth* (dd/mm/yyyy)Gender:*MaleFemaleTransgenderAboriginal and/or Torres Strait Islander:*YesNoCLINICAL INFORMATIONCurrent opioid substitution therapy:*YesNoUnknownInjecting drug use (any in last 6 months):*YesNoUnknownCirrhosis:*Yes, determined by FibroScanYes, determined by APRINoHBsAg*YesNoUnknownHBcAb*YesNoUnknownHIV infection:*YesNoUnknownFibroScan score (if available):E.g. 00.0 kPaHCV genotype:*1a1b23456AST (U/L):Please enter a value greater than or equal to 0.Upper limit of normal:Please enter a value between 0 and 99.HCV RNA level:< 6 million IU/mL> 6 million IU/mLUnknownALT (U/L):Please enter a value greater than or equal to 0.Platelets (10^9/L):Please enter a value greater than or equal to 0.Creatinine (µM/L):Please enter a value between 0 and 9999.eGFR (mL/minBSAc):Please enter a value greater than or equal to 0.APRIHCV THERAPYPrevious HCV treatment:*NoYes, interferon-containingYes, interferon-freeTick if this is a previously enrolled REACH-C patient undergoing retreatment Yes please specify:*If previous HCV treatment was interferon-freePlanned HCV regimen:*sofosbuvir/ledipasvir (Harvoni®)sofosbuvir + daclatasvir (Sovaldi® + Daklinza®)sofosbuvir + ribavirin (Sovaldi® + Ibavyr®)paritaprevir/ritonavir/ombitasvir + dasabuvir (Viekira Pak®)paritaprevir/ritonavir/ombitasvir + dasabuvir + ribavirin (Viekira Pak-RBV®)sofosbuvir/velpatasvir (Epclusa®)grazoprevir/elbasvir (Zepatier®)grazoprevir/elbasvir + sofosbuvir (Zepatier® + Sovaldi®)Ribavirin:YesNoPlanned duration:*8 weeks12 weeks16 weeks24 weeksDate of authority prescription:* (dd/mm/yyyy). If unknown, proposed dateScheme:*S100S85Data on treatment outcome including adherence and reasons for treatment failure will be collected at the SVR12 time pointInformation required for specialist approvalThe following information is required for specialist approval but will not be collected for REACH-C studyPatient Body weight:*E.g. 85.0 kgEtOH current (g/day):*Please enter a value between 0 and 99.List of current comorbidities:List of other concurrent medication:Drug-drug interactions reviewed:*YesNo(please check result from HEP Drug Interaction Checker at http://www.hep-druginteractions.org/) Action needed:e.g. note any change in medication, dose reduction requiredAssessed for adherence:*YesNoe.g. note any change in medication, dose reduction requiredNotes:OUTCOME (to be completed at SVR12)Deadline of SVR outcome completion DD MM YYYY (dd/mm/yyyy)Deadline of SVR outcome completion (8 wk plan) DD MM YYYY (dd/mm/yyyy)Deadline of SVR outcome completion (12 wk plan) DD MM YYYY (dd/mm/yyyy)Deadline of SVR outcome completion (16 wk plan) DD MM YYYY (dd/mm/yyyy)Deadline of SVR outcome completion (24 wk plan) DD MM YYYY (dd/mm/yyyy)Sustained virological response:YesNoUnknownNumber of complete days of treatment missed:Please enter a value between 0 and 180.Reason for non-SVR:relapsereinfectionlost to follow updeathif applicable – if patient will get re-treatment, please complete a new formCause of death:genotype:1a1b23456SignatureAdditional Comment:Your full name:*SPAM protectionSPECIALIST APPROVALSpecialist name:Specialist sign-off:on (dd/mm/yyyy)Result:ApprovedPatient requires specialist referral/assessmentNeeds further dataPhoneThis field is for validation purposes and should be left unchanged.