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:*YesNoHBsAg*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®)sofosbuvir/velpatasvir (Epclusa®)grazoprevir/elbasvir (Zepatier®)grazoprevir/elbasvir + sofosbuvir (Zepatier® + Sovaldi®)glecaprevir/pibrentasvir (Maviret®)sofosbuvir/velpatasvir/voxilaprevir (Vosevi®)Ribavirin:YesNoPlanned duration:*8 weeks12 weeks16 weeks24 weeksDate of authority prescription:* (dd/mm/yyyy). If unknown, proposed dateScheme:*S100S85You will be contacted by the REACH-C study team to collect the 12 week post-treatment outcome and adherence for this patient.Information 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:SignatureAdditional Comment:Your full name:*SPAM protectionSPECIALIST APPROVALSpecialist name:Specialist sign-off:on (dd/mm/yyyy)Result:ApprovedPatient requires specialist referral/assessmentNeeds further dataNameThis field is for validation purposes and should be left unchanged.