Cancer Survivorship: Patient Case Form

Welcome to ECHO Idaho's Cancer Survivorship Case Submission Form.

Please complete as much of the form as you can. We understand you might not have all the data. Please do not include any specific client specific of Protected Health Information (PHI). If you have any questions regarding this form, please contact [email protected].

Presenter First and Last Name *

Credentials *

Phone Number *

Clinical Site *

City *

Email *

ECHO Idaho offers $100 in compensation for case presentations. Would you like to accept compensation for presenting this case? *

Yes (ECHO staff will reach out to you with compensation paperwork that must be completed three weeks prior to your presentation date.)

No, I would like to donate my time.

Please do not include any identifiable patient/client information, Personally Identifiable Information (PII), or Protected Health Information (PHI). If you have any questions regarding this form, please contact [email protected]. *

Click here to acknowledge.

PRIMARY QUESTIONS

What particular questions or challenges would you like input on from the ECHO panel?

PATIENT INFORMATION

Patient Age

Sex at Birth

Female

Male

Insurance Type

Private

Medicaid

Medicare

CANCER HISTORY AND TREATMENT

What findings guided suspicion or diagnosis of cancer?

What findings guided suspicion or diagnosis of cancer? Other...

Briefly describe the findings that guided suspicion or diagnosis of cancer.

Diagnosis Date (year)

Type, Location, Histology Subtype

Describe the stage of cancer (e.g., Stage I-IV)

Initial Treatment Other, please specify.

Describe treatment

Date and specifics (procedure, location, findings)

List pre-existing comorbidities

List cancer-related comorbidities

Medications

List medications & dose (indicate past or current if known).

Is this patient still in treatment?

Yes

No

End of Treatment Date (year)

ADDITIONAL CONTEXT

Are there any known genetic or hereditary risk factors or predisposing conditions?

Yes

No

Describe additional genetic or hereditary risk factors or predisposing conditions.

Has the patient received genetic counseling?

Yes

No

Genetic test results (if available)

Social History

Advance Directives/Code Status

Has advance care planning taken place (advance directive, code status, etc)?

Yes

No

Survivorship Care Planning

Has a survivorship care plan been developed and/or shared with the patient (summary of treatment, recommended follow-up, surveillance, health promotion, and care coordination)?

Yes

No

In progress

Survivorship Care Planning Details

Briefly describe what the survivorship care plan includes (e.g., treatment summary, follow-up schedule, lifestyle recommendations, care coordination).

Goals of Care

What is important to the patient/family (physical, psychological, emotional, social, spiritual care)?

Thank you for completing ECHO Idaho's Cancer Survivorship 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.

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