1 Start 2 new page for Diabetes 3 New page met conditions 4 New Page for all 5 Complete Welcome to ECHO Idaho's Diabetes and Metabolic Conditions 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 or 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. You are responsible for ensuring that no identifiable patient/client information is included (e.g., photos, records), nor any Personally Identifiable Information (PII), Protected Health Information (PHI), or information protected under the Family Educational Rights and Privacy Act (FERPA). If you have any questions about this form, please contact [email protected]. * Click here to acknowledge. KEY QUESTIONS FOR ECHO IDAHO What specific questions or challenges would you like input on from the ECHO panel? (Diagnosis uncertainty? Medication selection? CGM initiation? Weight management? Metabolic syndrome?) Patient Age Sex at Birth Female Male Insurance Type Private Medicaid Medicare Self-pay PATIENT OVERVIEW Comorbidities Hypertension Dyslipidemia Obesity NAFLD/NASH PCOS Sleep apnea ASCVD (coronary, cerebrovascular, peripheral artery disease) Neuropathy Retinopathy Nephropathy and/or CKD History of amputations Gastroparesis Thyroid disorders Depression/anxiety Other... Comorbidities Other... Context & Social Drivers of Health Select areas of concern affecting care Dietary patterns Physical activity level Alcohol/tobacco/substance use Anxiety/depression/stress Sleep Access (medications, healthy food, transportation, testing supplies, etc.) Language barrier Health literacy considerations Financial/insurance barriers Housing instability Family support Family history of diabetes/metabolic conditions Other (please note additional contextual information) Context & Social Drivers of Health Other (please note additional contextual information) Has this this patient been diagnosed with diabetes? Yes No Leave this field blank
