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)" or a blank space to move to next question.
 
Do not include and Protected Health Information (PHI). 
 
By submitting this survey you have acknowledged  that Project ECHO case consultations do no 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. Please tell us what you’d like us to know about your patient:

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* 5. What medical information is pertinent:

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* 6. Please indicate any psychiatric history or concerns.

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* 7. Please address substance use.

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* 8. Labs/imaging (UA drug tests):

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* 9. Pertinent physical findings:

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100% of survey complete.

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