Dementia ECHO – Patient Case

To submit a case, fill out the form below.

Prefer to complete it in your own time? Download this form and email it to the contact listed on the form.

If you have any questions about this case form, please contact jrienstra@npaihb.org or echo@npaihb.org.

Your Name(Required)

Basic Information

MM slash DD slash YYYY

Behavioral Health History

Diagnosed or Symptomatic:
Depression
Description
Anxiety
Description
Mania/Hypomania
Description
Agitation
Description
Insomnia/Drowsiness
Description
Wandering
Description
PTSD
Description
Other (Please Describe)
Description
Has patient been hospitalized?
Description
(3-4 sentences)

Cognitive Screening Exams

EXAMS:
SLUMS
Findings
MMSE
Findings
MoCA
Findings
Mini-Cog
Findings

Current Medications

List
Medication Name
Dosage
Frequency
 

Check all that apply (or relate to main question) and fill in specifics:

Specific symptom management (e.g., insomnia, wandering, paranoia, hallucinations, etc.)
Description
Dementia specific treatment options
Description
Issues of Activities of Daily Living (ADLs)
Description
Issues of Instrumental Activities of Daily Living (iADLs)
Description
Determining the patient’s diagnosis
Description
Agitation and/or aggression management
Description
Advance care planning
Description
Behavior management
Description
Other(s)
Description

By submitting this form, you have acknowledged that Project ECHO case consultations do not create or otherwise establish a provider-patient relationship between an ECHO clinician and any patient whose case is being presented in a teleECHO session. Always use Patient ID# when presenting a patient in clinic. Sharing patient name, initials or other identifying information violates HIPAA privacy laws.