If your client has elevated liver enzymes, please answer the following :


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  How long has the abnormality been present ? 


   2.  Date and results of the most recent liver enzyme tests :
       AST/SGOT: 
       ALT/SGPT: 
       GGTP:     


   3.  Have these results been ?
        Increasing
        Decreasing
        Stable
        Fluctuating Up and Down
        Unknown


   4.  Does your client drink alcohol ?
        Yes, please provide amount and frequency: 
        No
        Drinking Pattern Changed Recently 


   5.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   6.  Select the following studies that have been completed ?
       Hepatitis A, B or C           Normal   Abnormal 
       Iron Studies                  Normal   Abnormal
       Liver Ultrasound or CT Scan   Normal   Abnormal
       Liver Biopsy                  Normal   Abnormal
       No Further Evaluation        


   7.  Does your client have any major health problems ? Yes   No 

       (example: cancer, etc.)

       If yes, give details: