FAIL: K12_Autism_Patient_Case_Form

ECHO Autism STAT Case Presentation Form

Complete this form to the best of your ability. This survey is individualized and should only be completed and submitted by the listed clinician. A unique confidential patient ID number has been provided that must be utilized when identifying your patient during clinic.

Email ECHO Idaho at [email protected] if you have any questions or comments.

PLEASE NOTE: ECHO Idaho de-identified case discussions do not create or otherwise establish a clinician-patient relationship. All information is de-identified and the participants and content experts are engaged in case-based learning.

Please provide your contact information

First Name

Last Name

Credentials

Email

Name of Clinic

City

State

Presentation Type

New

Follow-up

Patient Outcomes

Is this patient an existing patient or new patient?

Existing patient

New patient

How long has the child been in your care

Who referred the child to you (ECHO Autism Clinician)?

Who referred the child to you (ECHO Autism Clinician)? Other, please specify.

Please specify physician/practitioner

In your practice

Outside your practice

Please specify the type of outpatient therapy

Please specify the type of outpatient therapy Other, please specify:

Please specify the type of community resource

Infant-toddler Program

Parents-as-Teachers

Other, please specify:

Please specify the type of community resource Other, please specify:

Is this patient currently on another waitlist for a diagnostic evaluation?

Yes

No

I don't know

How long is the wait?

How long did the patient wait to see you, the ECHO Autism Clinician, to START their autism assessment?

Approximately how long does it take the patient to drive to your office? (Hours and Minutes)

History of the Present Illness (HPI) and other questions you would like help with.

Please briefly summarize the HPI (from the first sign and/or symptom or from the previous encounter to the present).

What is your presenting question/concern?

Additional questions/concerns?

Birth History

Exposures during pregnancy: (select all that apply)

Exposures during pregnancy: (select all that apply) Other, please specify:

Gestational age (in weeks)

Birth weight (in pounds and ounces)

Delivery mode:

Vaginal

C-Section

Unknown

If C-section, why?

Delivery mode: If C-section, why?

Presentation:

Breech

Head first

Unknown

Were there newborn problems?

Yes

No

If yes, please explain.

Were there newborn problems? If yes, please explain.

Please check all of the following that apply:

Please check all of the following that apply: Other, please explain.

Comments about birth history:

Developmental History

Communication Ability (Please indicate the child's highest form of communication/s)

Nonverbal (e.g., no functional words)

Uses single words

Uses 2-3 word phrases

Uses sentences

Chats with others

Uses gestures (e.g., pointing, waving and/or leads others to wants/needs)

Behavior Concerns (check all that apply)

Do parent share your concern about autism?

Has there been significant loss of an acquired skill or skills?

Yes

No

Explain significant loss:

Comments on developmental history

Review of Systems

Symptoms:

	Yes, stable	Yes, NOT stable	No	Not assessed
Headaches	Headaches - Yes, stable	Headaches - Yes, NOT stable	Headaches - No	Headaches - Not assessed
Staring spells/tremors/tics/seizures	Staring spells/tremors/tics/seizures - Yes, stable	Staring spells/tremors/tics/seizures - Yes, NOT stable	Staring spells/tremors/tics/seizures - No	Staring spells/tremors/tics/seizures - Not assessed
Hearing or vision concerns	Hearing or vision concerns - Yes, stable	Hearing or vision concerns - Yes, NOT stable	Hearing or vision concerns - No	Hearing or vision concerns - Not assessed
ENT (chronic ear infections, sinusitis)	ENT (chronic ear infections, sinusitis) - Yes, stable	ENT (chronic ear infections, sinusitis) - Yes, NOT stable	ENT (chronic ear infections, sinusitis) - No	ENT (chronic ear infections, sinusitis) - Not assessed
Dental problem	Dental problem - Yes, stable	Dental problem - Yes, NOT stable	Dental problem - No	Dental problem - Not assessed
Heart problems	Heart problems - Yes, stable	Heart problems - Yes, NOT stable	Heart problems - No	Heart problems - Not assessed
Lung problems	Lung problems - Yes, stable	Lung problems - Yes, NOT stable	Lung problems - No	Lung problems - Not assessed
Urinary/genital problems	Urinary/genital problems - Yes, stable	Urinary/genital problems - Yes, NOT stable	Urinary/genital problems - No	Urinary/genital problems - Not assessed
Diarrhea/constipation	Diarrhea/constipation - Yes, stable	Diarrhea/constipation - Yes, NOT stable	Diarrhea/constipation - No	Diarrhea/constipation - Not assessed
Stomach ache/pain/reflux	Stomach ache/pain/reflux - Yes, stable	Stomach ache/pain/reflux - Yes, NOT stable	Stomach ache/pain/reflux - No	Stomach ache/pain/reflux - Not assessed
Blood sugar/thyroid/growth problems	Blood sugar/thyroid/growth problems - Yes, stable	Blood sugar/thyroid/growth problems - Yes, NOT stable	Blood sugar/thyroid/growth problems - No	Blood sugar/thyroid/growth problems - Not assessed
Skeletal/bone/muscle problem/toe walking	Skeletal/bone/muscle problem/toe walking - Yes, stable	Skeletal/bone/muscle problem/toe walking - Yes, NOT stable	Skeletal/bone/muscle problem/toe walking - No	Skeletal/bone/muscle problem/toe walking - Not assessed
Food allergies	Food allergies - Yes, stable	Food allergies - Yes, NOT stable	Food allergies - No	Food allergies - Not assessed
Environmental allergies	Environmental allergies - Yes, stable	Environmental allergies - Yes, NOT stable	Environmental allergies - No	Environmental allergies - Not assessed
Skin problems (rash, eczema)	Skin problems (rash, eczema) - Yes, stable	Skin problems (rash, eczema) - Yes, NOT stable	Skin problems (rash, eczema) - No	Skin problems (rash, eczema) - Not assessed

Comments on review of systems:

Medications

Does this patient take any medications?

Yes

No

Currently, is the patient taking medications for any of the following? (select all that apply)

Currently, is the patient taking medications for any of the following? (select all that apply) Other

Please select which medications the patient is taking for sleep:

Melatonin

Clonidine

Other, please specify:

Please select which medications the patient is taking for sleep: Other, please specify:

Please select which medication(s) the patient is taking for constipation:

Polyethylene Glycol (MiraLAX)

Fiber

Docusate(Colace)

Please select which medication(s) the patient is taking for allergies/asthma:

Please select which medication(s) the patient is taking for allergies/asthma: Other, please specify:

Please select other medication(s) the patient is taking:

Testing: Which of the following have been completed for this patient?

Vision screening

Yes

No

Unknown

Vision screening results

Audiologic (hearing) screening

Yes

No

Unknown

Audiologic results

Lead blood level

Yes

No

Unknown

Lead blood level results

Chromosomal microarray

Yes

No

Unknown

Chromosomal microarray results

Karotype

Yes

No

Unknown

Karotype results

Fragile X DNA

Yes

No

Unknown

Fragile X DNA results

MRI of the brain

Yes

No

Unknown

MRI of the brain results

EEG

Yes

No

Unknown

EEG results

Sleep study

Yes

No

Unknown

Sleep study results

Comments on testing

Dietary/Nutrition/Metabolic

Please check all of the following dietary/nutrition/metabolic symptoms that apply:

Problem eater (Fewer than 10 foods)

Picky eater (Fewer than 20 foods)

Special Diet

Pica (Eating/craving non-food items)

Chewing or swallowing issues

History of growth concerns - Overweight

History of growth concerns - Underweight

Which beverages does the child drink regularly?

Water

Milk

Juice/sweetened beverages

Approximately how much milk does the child drink per day? (in ounces)

Approximately how much water does the child drink per day? (in ounces)

Approximately how much juice does the child drink per day?

What food groups does the child avoid?

Does the child consume meals and snacks at regular times each day?

Yes

No

Does the child communicate hunger or thirst?

Yes

No

Does the child take supplements?

Yes

No

Please specify supplements:

Comments on dietary/nutrition/metabolic concerns:

Sleep History Rarely=never or 1 time/week; Sometimes=2-4 times/week; Usually=5 or more times/week

Does the child fall asleep within 20 minutes?

Is falling asleep a problem?

Does the child co-sleep?

With whom does the child sleep? Other, please specify:

Is co-sleeping a problem?

Does the child awaken more than once during a night?

Are nighttime awakenings a problem?

Does the child snore loudly?

Is snoring a problem?

Does the child seem tired during the day?

Is tiredness during the day a problem?

Comments about sleep:

Trauma/Abuse History

Which of the following have been experienced by the child:

	No	Yes	Unknown
Trauma/abuse history	Trauma/abuse history - No	Trauma/abuse history - Yes	Trauma/abuse history - Unknown
Physical abuse	Physical abuse - No	Physical abuse - Yes	Physical abuse - Unknown
Sexual abuse	Sexual abuse - No	Sexual abuse - Yes	Sexual abuse - Unknown
Witness to abuse	Witness to abuse - No	Witness to abuse - Yes	Witness to abuse - Unknown

Trauma/abuse comments:

Social History

Child resides with: Other, please specify:

Has legal custody of the child Other, please specify:

Biological parents are:

How many people live in the home not including the child?

You are here