Down Syndrome ECHO Initial Case Presentation Form

Down Syndrome ECHO Initial Case Presentation Form

Project ECHO® (Extension for Community Healthcare Outcomes)
Submission Date

MonthDayYear
Date
Provider Details

NameClinical Site
Provider Email
example@example.com
Provider Phone
Please enter a valid phone number.
Provider Fax
Please enter a valid fax number.
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

MonthDayYear
Date
Case Presentation
Check One

New CaseFollow-up
Age
Years (for 3 years and above) Months (for less than 3 years)
Biological Gender

MaleFemale
Race

American Indian/Alaskan NativeAsianBlack/African AmericanNative Hawaiian/Pacific HighlanderWhite/CaucasianMulti-RacialPrefer Not to SayOther
Ethnicity

Hispanic/LatinoNot Hispanic/LatinoPrefer Not to Say
Insurance
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/herselfFamilyStaff (e.g. residential staff)Other
Other health problems

HypothyroidismSleep apneaDiabetes mellitus type 1Diabetes mellitus type 2PrediabetesOther sleep disturbanceVision impairmentHearing impairmentHeart diseaseAlzheimer’s diseaseAutismGI DisordersDysphagiaOther
Psychiatric history:

Obsessive compulsive disorderDepressionAnxietyADHD—attention hyperactivity combinedBehavioral concernsPsychosesMood disorderOther
History of trauma or abuse
For those 18 and younger, please provide birth history
Special Diets
Supplements
Immunization status

Family History

	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 communicativeLimited verbal communicationVocalNon-verbal/Non-vocalAugmentative and alternative communicationOther non-verbal form of communicationOther
Residence (check all that apply)

Lives in own residenceLives with parentsLives with siblingsLives with other familyLives in residential facilityOther
“Protective” Factors: people and other support (check all that apply)

ParentsSiblingsOther relativesTeacherEmployerSchool counselorOther counselorHome care nurseChurch communityDown syndrome communityOther
Any change in the social environment? If yes, please describe.
Education
Occupational history
Religious beliefs

Health behaviors and activities

	Frequency	Type
Exercise
Activities

Pertinent Physical Exam Findings

Values

Height

Weight
Other information
Should be Empty:

	Values
Height
Weight

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