CHECK LIST AND REFERRAL FORM FOR ABNORMAL LFTs
(INCLUDES “LIVER SCREEN”)
Contact
details:
GSTT
KCH
Other
Address
Phone
Fax
Email
Referral Date
Referring Clinician
Practice Details
~[Today...]
~[Free Text:Referring
Clinician?]
~[Surgery Address Line
1]
~[Surgery Address Line
2]
~[Surgery Address Line
3]
~[Surgery Address Line
4]
~[Surgery Address Line
5]
~[Surgery Tel No.]
Patient Name
DOB
~[Forename] ~[Surname]
~[Date Of Birth]
Patient Address
~[Patient Address Block]
Patient Tel
Mobile
~[Telephone Number]
~[Mobile]~[Mobile
Number]
~[NHS Number]
~[Hospital Number]
NHS Number
Hospital Number

This form is not appropriate for decompensated liver failure. Please seek urgent
advice from gastroenterology/hepatology for patients with abnormal LFTs in the
following groups:
1. abnormal INR/abnormal albumin
2. symptomatic/ jaundiced/clinically unwell

Patients with a significant alcohol history, and moderately abnormal LFTs
(<1.5xnormal) should be given lifestyle advice and the test repeated at a 3 month
interval in the first instance.

Remember to consider and exclude drug induced causes of hepatitis. Take
appropriate action following guidance from the BNF or the drug summary of product
characteristics (http://www.medicines.org.uk/EMC/default.aspx)

Please fill in the boxes below or attach all relevant results.
Final Version March 2013
HISTORY
Alcohol consumption (units/week)
FAST questionnaire score
Smoking history
Medications
Diabetes? Include year of diagnosis,
treatment and recent HbA1c.
Clinical Values
Date
BP
Weight and BMI
Blood Results
FBC
U&E
Lipid profile
HbA1c
ALT
AST
ALP
GGT
Bilirubin
(isolated raised bilirubin
in an
asymptomatic patient is likely
gilberts, a benign
condition,please do not refer)
Final Version March 2013
Date
Date (Please show
trend where possible)
INR (document
warfarin therapy)
Albumin
Further investigations(“Liver screen”)
Date
Hepatitis Serology A, B and C (if positive
refer to hepatitis clinic using appropriate form)
HIV
Liver auto antibodies
Iron studies (include ferritin)
Ultrasound
Do you suspect non alcoholic
fatty liver disease (fat on USS
and centrally obese/diabetic
patient)?
Y/N
Please see attached flow
chart for management of
NAFLD by GPs
FIB 4 Score =
Please explain below

Why are you referring this patient now?

What action/investigations/advice you have given already?

Any further information you feel relevant?
Final Version March 2013