1. Your Case Presentation Information

Describe your case and your main question you would like addressed by the ECHO participants.
 
Note: If you do not have information for a category, just insert "unknown", "not applicable (NA)"  to move to next question.
 
Do not include any Protected Health Information (PHI). 
You may email PHI free documents to Midwest.Tribal.Echo@hcmed.org or Fax attn: Michelle Corcoran to 612-872-8547.
 
By submitting this survey you have acknowledged  that Project ECHO case consultations do not create or otherwise establish a provider-patient relationship between any ECHO clinician and any patient whose case is being presented in a teleECHO clinic.

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* 1. Your name and your clinic name.

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* 2. Patient demographics

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* 3. Please state your KEY QUESTION:

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* 4. Current substance use (check all that apply):

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* 5. Past substance use (check all that apply):

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* 6. Specify substance, route, frequency, duration of current or past use.

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* 7. MAT History:

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* 8. Treatment History:

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* 9. Mental health conditions/medications:

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* 10. Chronic health conditions/medications:

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* 11. Social supports/barriers:

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* 12. Legal/CPS involvement:

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* 13. Personal history of trauma:
Examples, foster care, sexual abuse, neglect

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* 14. Other relevant information:

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100% of survey complete.

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