Endocrinology TeleECHO Program Case Presentation Form Cover Sheet Complete ALL ITEMS on this form and email to Dragana Lovre, MD (DLovre@Tulane.edu) Sessions held every other Tuesday at 11:45AM Central Time . 1. Presenter Name and Credentials*: 2. Presenter Cell Phone Number*: 3. Presenter Email*: 4. Clinic/Facility Name and City*: When do you want to present your case? * We need your contact information to confirm case receipt and to notify you if the case needs to be rescheduled. PLEASE NOTE that Project ECHO® case consultations do not create or otherwise establish a provider-patient relationship between any Tulane University clinician and any patient whose case is being presented in a Project ECHO® setting. 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 the session. We are working hard to change the language around diabetes by adopting person-centered, strengths-based, and empowering words and messages. Please avoid using “diabetic,” “compliant,” “adherent,” or “control,” when presenting people who have diabetes. Instead, use “person with diabetes,” “diabetes-related,” and “he takes his medications about half the time.” We will all learn and practice this together – thanks for your support! The information on this form is privileged and confidential. It is intended only for the use of the recipient at the location above. If you have received this in error, any dissemination, distribution or copying of this communication is strictly prohibited.
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Endocrinology TeleECHO Program Case Presentation Form Cover Sheet
Complete ALL ITEMS on this form and email to Dragana Lovre, MD ([email protected]) Sessions held every other Tuesday at 11:45AM Central Time .
1. Presenter Name and Credentials*:
2. Presenter Cell Phone Number*:
3. Presenter Email*:
4. Clinic/Facility Name and City*:
When do you want to present your case?
* We need your contact information to confirm case receipt
and to notify you if the case needs to be rescheduled.
PLEASE NOTE that Project ECHO® case consultations do not create or otherwise establish a provider-patient relationship between any Tulane University clinician and any patient whose case is being presented in a Project ECHO® setting.
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 the session.
We are working hard to change the language around diabetes by adopting person-centered, strengths-based, and empowering words and messages. Please avoid using “diabetic,” “compliant,” “adherent,” or “control,” when
presenting people who have diabetes. Instead, use “person with diabetes,” “diabetes-related,” and “he takes his medications about half the time.” We will all learn and practice this together – thanks for your support!
The information on this form is privileged and confidential. It is intended only for the use of the recipient at the location above. If you have received this in error, any dissemination, distribution or copying of this communication is strictly prohibited.
Diabetes (Adult)
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Endocrinology TeleECHOTM Program— DIABETES (ADULT) CASE PRESENTATION TEMPLATE —
PLEASE NOTE that Project ECHO® case consultations do not create or otherwise establish a provider-patient relationship between any Tulane clinician and any patient whose case is being presented in a Project ECHO setting.
Substance Use History: Does the patient have any history of substance use? ☐No ☐Yes Describe: _____________________________________________________________________________ Does Patient Use Tobacco Products? ☐No ☐Yes – Number per day (1 pack = 20): _____________________
Does Patient Drink Alcohol? ☐No ☐Yes – Number of drinks per week: _______________________________
Nutrition: # of meals per day: _____ Frequency of dining out/week: _____ ☐ Fast Food, ☐ Family Restaurant, ☐
Casino, ☐ Other_____________________________ Please attach a food diary
Does patient count carbs? ☐ No ☐ Yes Use of vitamins and/or herbs: ☐No ☐Yes
Who shops for groceries? ☐ Patient, ☐ Spouse/Partner, ☐ Other Family, ☐ Caregiver, ☐ Other: _____________