ADRD: Patient Case Form

Welcome to ECHO Idaho's Alzheimer's Disease and Related Dementias Patient 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 echoidaho@uidaho.edu.

Presenter first and last name *

Credentials *

Email *

Phone number *

Organization *

City *

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 echoidaho@uidaho.edu. *

Click here to acknowledge.

Gender Identity

Female

Male

Transgender

Other, please specify.

Gender Identity Other, please specify.

Age

Briefly describe the concerns for your patient and the questions you have for the ADRD ECHO Panel. *

Check all that apply or relate to your main question.

Behavioral symptoms: Aggression, sexually inappropriate behavior, wandering, elopement, safety concerns

Psychiatric symptoms: mood, paranoia, hallucinations, anxiety, insomnia

Issues with ADLs and IADLs including toileting/incontinence, showering, sensory loss

Diagnostic clarification

Advance Care Planning

Caregiver support

Medication recommendations

Other, please specify.

Check all that apply or relate to your main question. Other, please specify.

Has your patient every been formally diagnosed with dementia or another brain health condition?

Yes, they have been diagnosed

No, they have not been diagnosed but are showing signs of possible brain condition

I don't know if they have been diagnosed

Please provide more information about the diagnosis.

Pertinent Labs

	Normal	Abnormal
CBC	CBC - Normal	CBC - Abnormal
CMP	CMP - Normal	CMP - Abnormal
A1c	A1c - Normal	A1c - Abnormal
Lipids	Lipids - Normal	Lipids - Abnormal
TSH	TSH - Normal	TSH - Abnormal
B12	B12 - Normal	B12 - Abnormal
Vitamin D	Vitamin D - Normal	Vitamin D - Abnormal
HIV	HIV - Normal	HIV - Abnormal
RPR	RPR - Normal	RPR - Abnormal

Please elaborate on any lab abnormalities from above and other pertinent results (folate, MMA, homocysteine, etc.).

What neuroimaging has been completed and what were the results?

Please list the medications used (indicate past or current if known):

If cognitive screening has been completed, please provide test type, score, date (e.g. SLUMS, CPCOG, MMSE, MoCA, MINI-COG)?

Relevant substance use history: Other, please specify.

Social History: Please describe patient's living arrangements (Where? With whom? Who provides care?) and any other concerns.

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

Please add any additional contextual information about this case, if appropriate.

Thank you for completing ECHO Idaho's ADRD 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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