Down Syndrome ECHO Initial Case Presentation Form
Project ECHO® (Extension for Community Healthcare Outcomes)
Submission Date
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Month
/
Day
Year
Date
Provider Details
Name
Clinical Site
Provider Email
example@example.com
Provider Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Fax
Please enter a valid fax number.
Format: (000) 000-0000.
Echo ID
When we receive your case, we will email you with a confidential patient ID number (ECHO ID) that must be utilized when identifying your patient during clinic and a date of presentation.
Date of Echo presentation
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Month
/
Day
Year
Date
Case Presentation
Check One
New Case
Follow-up
Age
Years (for 3 years and above) Months (for less than 3 years)
Biological Gender
Male
Female
Race
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Pacific Highlander
White/Caucasian
Multi-Racial
Prefer Not to Say
Other
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Prefer Not to Say
Insurance
Please Select
None
Medicaid
Medicare
Private
What is the main question about this patient?
What diagnosis has the patient been given for the present concerns
What evaluation has been done
What treatments have been given and outcomes
Other (please elaborate)
Who provides the history for this patient? (Check all that apply)
Patient him/herself
Family
Staff (e.g. residential staff)
Other
Other health problems
Hypothyroidism
Sleep apnea
Diabetes mellitus type 1
Diabetes mellitus type 2
Prediabetes
Other sleep disturbance
Vision impairment
Hearing impairment
Heart disease
Alzheimer’s disease
Autism
GI Disorders
Dysphagia
Other
Psychiatric history:
Obsessive compulsive disorder
Depression
Anxiety
ADHD—attention hyperactivity combined
Behavioral concerns
Psychoses
Mood disorder
Other
History of trauma or abuse
For those 18 and younger, please provide birth history
Special Diets
Supplements
Immunization status
Family History
Rows
Yes
No
Headaches
Genetic conditions
Cancer
Diabetes Type 1
Diabetes Type 2
Alzheimer’s disease
Other dementia
Depression
Anxiety
Bipolar
Obsessive-compulsive disorder
Other Family History
Mode of Communications (check all that apply)
Verbally communicative
Limited verbal communication
Vocal
Non-verbal/Non-vocal
Augmentative and alternative communication
Other non-verbal form of communication
Other
Residence (check all that apply)
Lives in own residence
Lives with parents
Lives with siblings
Lives with other family
Lives in residential facility
Other
“Protective” Factors: people and other support (check all that apply)
Parents
Siblings
Other relatives
Teacher
Employer
School counselor
Other counselor
Home care nurse
Church community
Down syndrome community
Other
Any change in the social environment? If yes, please describe.
Education
Occupational history
Religious beliefs
Health behaviors and activities
Rows
Frequency
Type
Exercise
Activities
Pertinent Physical Exam Findings
Rows
Values
Height
Weight
Other information
Submit
Should be Empty: