Treating the Disease of Obesity ECHO Program

Case Submission Form

Please complete the below form with information that is relevant to your question(s), so that the other ECHO participants can give their best recommendations to you.

To protect patient privacy, please only include information that cannot be linked back to a patient - including but not limited to - names, locations, dates, employment, or other common identifiers.

Presenter Information

Case Presenter's First Name:

Case Presenter's Last Name:

Case Presenter's Email:

Key Question(s)

Please state your main question(s) for this case

Patient Information

Age:

Gender/ Gender Identity:

Height:

Weight:

BMI:

Heart Rate:

Blood Pressure:

Ethnicity:

Race:

Lab Results:

Glucose:

Insulin Level:

HOMA-IR:

HbA1C:

Liver Function test (ALT):

Liver function test (AST):

Lipid profile (TC):

HDL:

LDL:

TSH:

Free/Total Testosterone:

Vitamin D:

Other:

Medical History

What is the working diagnosis?

How long has the patient had this condition?

What previous procedures and/or diagnostic tests were performed?

What therapies have been tried?

Is there relevant past medical, social, and/or family history that is pertinent to this case?

Medications/ Allergies

List all current medications and relevant supplements:

List all known allergies:

Additional Information

If the patient is less than 18 years old, you may upload a growth chart. *All images must be de-identified and HIPAA compliant.

Is there any other relevant information that you would like to include?

Are there any photos/images you would like to include with this case? *All images must be de-identified and HIPAA compliant.

Obesity Medicine Association