Gender :	MaleFemale
Alk Phos :
AST :
ANA or AMSA or Anti LKM :	Negative1:401:80> 1:80
Anti-SLA, Anti-Actin, Anti-LC1, pANCA :	NegativePositive
Immunoglobulin G :	Normal1-1.5 times upper limit of normal1.5-2 times upper limit of normal> 2 times upper limit of normal
AMA :	NegativePositive
Histology :	None of the below optionsInterface HepatitisPlasmacytic InfiltrateRosettesBiliary ChangesOther Features
HLA DR3 or DR4 :	NegativePositive
Hx of Autoimmune Disease :	NegativePositive
Viral Serologies :	Hep A/B/C positiveNo positive viral markers
Drug History :	NegativePositive
Alcohol :	< 25 gm/dayBetween 25 and 60 gm/day> 60 gm/day
Treatment :	Not yet treatedComplete ResponseRelapse
Using ukat/L for AST? :

Formula :

Composite score of listed variables. Points given for each variable.

Explanation of Result :

Pretreatment Score:

> 15 is consistent with definite diagnosis. 10-15 is consistent with probable diagnosis.

Post-treatment Score:

> 17 is consistent with definite diagnosis. 12-15 is consistent with probable diagnosis.

* Please verify all calculations prior to clinical use.