LIVER REPORT


Patient Name: _______________________________________

Social Security #: _____________________________________

Date of Birth: ________________________________________

TO THE DOCTOR: Please complete the following report attaching copies of lab results for each condition. Please use the back of the form if additional space is needed.

1. Does this patient suffer from any liver impairment or disease?    ____YES  ____NO.  
If yes,

A. What is the current diagnosis? ___________________________________________
____________________________________________________________________
B. On what date was the diagnosis first made? _________________________________
C. What is the date of onset, if different? ______________________________________
D. How long have you been treating the condition? ______________________________
E. What is the date of the most recent examination? _____________________________
F. What was the patient's height_____ weight ____ at that time?

NOTE: If the diagnosis is also chronic alcoholism substance abuse or carcinoma, alternate forms will be provided.
2. Is the liver condition acute _____Yes _____No or chronic _____Yes _____No?

3. Is it due to:
      A. primary hepatic disorder? Yes_____ No_____
      B. a systemic disorder involving the liver? ____ YES ____NO
      If so, which disorder? ______________________________________
      C. Abuse of or dependence on alcohol or other drugs? ____ YES ____NO
4. Is there cholecystitis of intraheptic origin? Yes_____ No______
    Is there cholecystitis of extraheptic origin? Yes_____ No______
5. Are there complications? If so, describe ______________________________________
     ____________________________________________________________________
6. Have you palpated the liver? Yes_____ No_____
     If so, describe the results_________________________________________________
     ____________________________________________________________________
      Is there: Yes No Date
      enlargement ____ ____ ________
      rapid shrinking ____ ____ ________
      unusual firmness ____ ____ ________
      other abnormality ____ ____ ________
      describe_______________________________________________________
7. What are the lab values for: Value Date(s)
    serum bilirubin _______ _______
    alkaline phosphatase _______ _______
    serum aminotransferase
    (AST-formerly SGPT)		 _______ _______
    alanintransferase
    (ALT - formerly SGPT)		 _______ _______
    other _______ _______
8. What is the prothrombin? Value Date(s)
_______ _______
_______ _______
9. Are there enzyme abnormalities? Yes______              No_______
If so, what________________________________________ Date___________
________________________________________________ Date___________
10. Is there hypoalbuminemia of 3.0gm or less? Yes______              No_______
11. What diagnostic procedures have been performed
Date(s) Results
    biopsy _______ _______
    paracentesis _______ _______
    peritoneoscopy _______ _______
    needle biopsy _______ _______
    endoscopy _______ _______
    x-ray _______ _______
    other _______ _______
12. Has surgery been recommended? Yes______ No_______. If so, what procedure?
__________________________________________________________________
__________________________________________________________________
13. Has surgery been performed? Yes______ No_______. If so,
when _____________________________________________________________
where ____________________________________________________________
procedure _________________________________________________________
results ____________________________________________________________
14. Does the patient suffer from esophagel varices? Yes______ No_______.
If so, when was it first diagnosed?________________________________________
Have there been hemorrhages attributable to the varices? Yes______ No_______.
Date(s)?____________________________________________________________
15. Does patient have ascites not attributable to other causes? Yes______ No_______
If so, when was it first observed?_________________________________________
__________________________________________________________________
__________________________________________________________________
Duration____________________________________________________________
__________________________________________________________________
16. Is there hepatic cell necrosis or inflammation? Yes______ No_______
If so, for how long has it persisted?_________________________________________
17. Is there portal hypertension? Yes______ No_______ If so, for how long has it persisted?
__________________________________________________________________
What were the test results: _____________________________________________
__________________________________________________________________
18. Is the patient jaundiced? Yes______ No_______ If so, is it due to:
Yes No
    hemolysis _______ _______
    hepatocellular dysfunction _______ _______
    biliary obstruction _______ _______
    other__________________________________________________________
19. Has EEG been performed? Yes______ No_______. If so,
    Date(s)__________________________________________________________
    results__________________________________________________________
20. Is there hepatic or portal-systemic encephalopathy? Yes______ No_______
If so, what is the cause or precipitating event________________________________
__________________________________________________________________
__________________________________________________________________
Is there:
      Yes No Date
A. asterixis _____ _____ _______
B. cerebral edema _____ _____ _______
C. impaired consciousness _____ _____ _______
D. loss of cognitive abilities _____ _____ _______
E. affective changes _____ _____ _______
F. persistence of disorientation to time/place _____ _____ _______
G. memory impairment _____ _____ _______
H. perceptual or thinking disturbances _____ _____ _______
I. change in personality _____ _____ _______
J. disturbance in mood _____ _____ _______
K. emotional labality _____ _____ _______
L. loss of measured intelligence of at least 15 IQ points _____ _____ _______
M. marked restriction of activities of daily living _____ _____ _______
N. marked difficulty in maintaining social functioning _____ _____ _______
O. deficiencies of concentration _____ _____ _______
P. deficiences of persistence in pace _____ _____ _______
Q. repeated episodes of deterioration or decompensation in work or worklike setting _____ _____ _______
21. Does patient suffer from cirrhosis? Yes______ No_______
If so, what is the etiology?________________________________________________
____________________________________________________________________
When was it first diagnosed?______________________________________________
____________________________________________________________________
22. What clinical signs, in addition to the above, have you observed
      Yes No Date
A. anorexia _____ _____ _______
B. wasted extremities _____ _____ _______
C. peripheral edema _____ _____ _______
D. protuberant belly _____ _____ _______
E. glossitis _____ _____ _______
F. vascular spiders _____ _____ _______
G. splenomegaly _____ _____ _______
H. gynecomastia _____ _____ _______
I. parotid gland enlargement _____ _____ _______
J. hair loss _____ _____ _______
K. testicular atrophy _____ _____ _______
L. peripheral neuropathy _____ _____ _______
M. clotting disturbances _____ _____ _______
N. renal abnormalities _____ _____ _______
O. clubbing of fingers _____ _____ _______
P. weight loss _____ _____ _______
23.
What clinical signs, in addition to the above, have you observed
      Yes No Date
A. pruritus _____ _____ _______
B. pain _____ _____ _______
C. fatigue _____ _____ _______
D. weakness _____ _____ _______
E. nausea _____ _____ _______
F. malaise _____ _____ _______
G. vomiting _____ _____ _______
H. loss of libido _____ _____ _______
I. loss of appetite _____ _____ _______
J. abnormal sensation _____ _____ _______
24. What is the present therapy for the condition?_________________________________
____________________________________________________________________
25. What has been the response to treatment? ____________________________________
____________________________________________________________________
26. What medication has been precribed? _______________________________________
____________________________________________________________________
27. Are there any reported or observed side effects from the medication?
Yes______ No_______ If so, what are they?
__________________________________________________________________
28. What modifications to life style or daily living have been recommended?
__________________________________________________________________
29. What other medical or psychological conditions does the patient suffer in addition to those described above?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
30. Are you treating these conditions? Yes______ No_______
Date Report Completed: ______________________________
Signature of Physician: ______________________________
Physician Name: ______________________________
Address: ______________________________
Telephone: ______________________________
Specialty: ______________________________

Law Office Of:
Jerrold S. Zivic
850 W. Jackson Blvd.
Suite 405
Chicago, IL 60607
800-400-4357