1. Project ECHO- Cervical Cancer Prevention case template
Instructions to fill out this template
All participants must comply with HIPPA regulations and not use any Patient Identifiers when submitting cases for review
Please briefly describe relevant aspects of your case and draft your question (s) at the end of the presentation
Pictures are welcome but not necessary
Send this form before the next ECHO clinic so the facilitators have some time to review your case and provide valuable feedback
your completed form to and cc
Be advised that this ECHO consultation does not create or otherwise establish a provider-patient relationship between any MD Anderson clinician and any patient whose case is being presented in a Project ECHO setting

2. Project ECHO- Cervical Cancer Prevention case template
Presenter’s name:
Clinical Site:
Role/ Title
Patient’s age:
Gender:
Type of services provided (select): Office, Home or community, phone, other
Diagnoses:
Assigned case # by ECHO team:

3. History Chief complaint of the patient:
Problems (List any problems from the list on slide 4):
Significant past medical surgical:
Medications:
Allergies:
Psycho-social-spiritual history
Ease to access healthcare/ utilization for the Patient
Family tree and support

4. ESAS (0-10 scale, 0=no symptom; 10 worst possible symptom in last 24 hours
Pain 1 2 3 4 5 6 7 8 9 10
or Did not assess
Fatigue
Nausea
Depression
Anxiety
Drowsiness
Shortness of breath
Appetite
Feeling of bell-being
Sleep/ other symptom

5. Physical Exam Temperature: Blood pressure: Pulse: Respiratory Rate:
O2 saturation:
ECOG performance status: (0= nl; 1=some symptoms; 2= in bed / chair less than 50% of time; 3= bed and chair greater than 50%; 4= confined to bed, no self care):
Pertinent findings:

6. Labs and Imaging
Please add pertinent labs (with normal values –ranges) images if any relevant

7. Assessment and Patient defined Goals of Care
What is important to the patients and their family?

8. Questions/ Discussion
Please state your questions for the ECHO team
Please describe what you would like the team to help you with