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. . CASE PRESENTATION TEMPLATE Diabetes/General Endocrinology Clinic Date: Your Name: Your Location: New Patient Follow-up Check One: Patient Name: Age: Occupation: Ethnicity: Educational Level: WHAT IS YOUR MAIN QUESTION ABOUT THIS PATIENT? Gender: Female Male DM: Type I Type II If female, history of: Gestational Diabetes PCOS Diabetes Complications: Yes No Amount: Current Smoker: Height: Weight: BMI: Yes No Amount: Alcohol Use: Waist Circumference: BP: Yes Yes Yes No Family History of DM? No Family History of CVD? No History of Comorbid Depression? Medications Diabetes Cholesterol Blood Pressure Mental Health and/or Pain Fasting Chol: LDL: HDL: Triglycerides: TSH: Glucose: Creatinine: HbA1C: Urine/Micro Alb: ALT: eGFR: Prevention of diabetes complications: Last foot exam: Last dental Exam: Last eye exam: Last diabetes education: Insurance Information: Medicare Medicaid Commercial Self-pay Other: PRINT AND FAX COMPLETED FORM TO (775) 327-5112 Contact Person: Troy Jorgensen, Program Coordinator, (775) 682-8481 or tjorgensen@med.unr.edu Project ECHO Main Office: (775) 682-7740 | http://med.unr.edu/echo 11-8-16 .

CASE PRESENTATION TEMPLATE …...CASE PRESENTATION TEMPLATE . Diabetes/General EndocrinologyClinic Date: Your Name: Your Location: Patient Name: Check One: New Patient Follow-up Age:

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Page 1: CASE PRESENTATION TEMPLATE …...CASE PRESENTATION TEMPLATE . Diabetes/General EndocrinologyClinic Date: Your Name: Your Location: Patient Name: Check One: New Patient Follow-up Age:

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CASE PRESENTATION TEMPLATE

Diabetes/General Endocrinology Clinic

Date: Your Name: Your Location:

New Patient Follow-up Check One: Patient Name:

Age: Occupation: Ethnicity: Educational Level:

WHAT IS YOUR MAIN QUESTION ABOUT THIS PATIENT?

Gender: Female Male DM: Type I Type II If female, history of: Gestational Diabetes PCOS

Diabetes Complications:

Yes No Amount: Current Smoker: Height: Weight: BMI:

Yes No Amount: Alcohol Use: Waist Circumference: BP:

Yes Yes Yes NoFamily History of DM? No Family History of CVD? No History of Comorbid Depression?

Medications

Diabetes Cholesterol Blood Pressure Mental Health and/or Pain

Fasting Chol: LDL: HDL: Triglycerides: TSH: Glucose:

Creatinine: HbA1C: Urine/Micro Alb: ALT: eGFR:

Prevention of diabetes complications:

Last foot exam: Last dental Exam: Last eye exam: Last diabetes education:

Insurance Information:

Medicare Medicaid Commercial Self-pay Other:

PRINT AND FAX COMPLETED FORM TO (775) 327-5112 Contact Person: Troy Jorgensen, Program Coordinator, (775) 682-8481 or [email protected]

Project ECHO Main Office: (775) 682-7740 | http://med.unr.edu/echo

11-8-16

.

.

mailto:[email protected]

http://med.unr.edu/echo

http://med.unr.edu/echo

mailto:[email protected]

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