1 Start 2 Complete

Welcome to ECHO Idaho's Women's Health in Primary Care Case Submission Form.

Please complete as much of the form as you can. We understand you might not have all the data; feel free to leave some sections blank if they are unknown.

Do not include any specific client or Protected Health Information (PHI). If you have any questions regarding this form, please contact [email protected]. 

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PRIMARY QUESTIONS

Examples: diagnosis, treatment options, menopause management, abnormal bleeding, pelvic pain, fertility, sexual health, hormone therapy, referral decisions, or care coordination.
What is the primary women's health concern or diagnosis? How long has the issue been present? What symptoms are most bothersome to the patient? What treatments or interventions have already been tried? What prompted the consultation now?

PATIENT INFORMATION

MEDICAL & REPRODUCTIVE HISTORY

If you have additional information about the medical history, please describe below.
Describe relevant family medical history.
At what age did the patient begin menstruating? When was her last menstrual period? Describe the typical menstrual cycle (How many days are there between periods? How many days does bleeding last? How many products are used per day? Does she experience pain, cramping, irregular bleeding, or skipped periods? Any recent changes?)
Please describe any relevant pregnancy, birth, and postpartum history, including prior pregnancies and outcomes, delivery methods, complications, and any ongoing health effects.

MEDICATIONS

List medications, dose & duration (include contraception, hormonal therapies, cardiovascular/metabolic medications, psychiatric medications, supplements, OTC medications, and other relevant therapies).
Describe the type of contraception used.

PHYSICAL ASSESSMENT

For example: Pelvic exam findings, breast exam findings, musculoskeletal findings

LABS, IMAGING & DIAGNOSTIC TESTING

Share relevant labs, imaging results, pathology results, and procedures performed.

CARE TEAM & SUPPORTIVE SERVICES

What specialists or services are currently involved?
What matters most to the patient? What outcomes is the patient hoping to achieve? Are there cultural, reproductive, spiritual, financial, or personal preferences that should influence recommendations?

Thank you for completing ECHO Idaho's Women's Health in Primary Care Case Submission Form:

  • Case consultations do not create or otherwise establish a provider-patient relationship between any clinician and any patient whose case is being presented in this clinical setting.
  • No personally identifiable health information (PHI) or personally identifiable information (PII) appears in answers on the above form, in compliance with HIPAA privacy laws.

You will receive a copy of your responses in the email you provided and be contacted by ECHO staff about presenting your case in a session or follow-up consultation with a panelist within two business days.