Diabetes and Metabolic Conditions: Patient Case Form

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 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.

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.

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

PRESENTING PROBLEM

Primary diabetes/metabolic concern prompting presentation:

(e.g., hyperglycemia, new diagnosis, medication intolerance, A1c worsening, weight concerns, suspected metabolic syndrome, unclear treatment pathway)

MEDICAL HISTORY

Diagnosis Date (year)

Most recent A1c (include date)

A1c Trend

History

Blood glucose patterns (if known):

fasting / post-prandial / overnight trends

Use of CGM?

Yes

No

Other, please specify.

Use of CGM? Other, please specify.

Any episodes of DKA or severe hypoglycemia?

If yes, describe

History of gestational diabetes?

If yes, describe

Current Diabetes Medications Other...

Supportive services offered or referred for this patient

Supportive services offered or referred for this patient Other...

ADDITIONAL CONTEXT

Non-diabetes Medications

Antihypertensives

Lipid-lowering therapy

Weight loss medications

Other...

Non-diabetes Medications Other...

Medication Barriers

Cost

Access/insurance limitations

Intolerance/side effects

Adherence challenges (e.g., work schedule, injection burden)

Pharmacy/coverage issues

Other...

Medication Barriers Other...

PHYSICAL EXAM & OBJECTIVE DATA

Social History

Advance Directives/Code Status

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

Yes

No

Goals of Care

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

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