The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

inpXuYqiC9y6HCmfjwVo9F4F7RyrYhZd

Cancer Survivorship for Primary Care ECHO Case Form

Please answer as many questions as possible without including any Protected Health Information or Personally Identifiable Information (PHI, PII).

If you wish to save your entries and complete the form at another time, click "Save & Return Later" at the bottom of this form. Then enter your email address and use the link you receive to return at your convenience.

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 ECHO session.

For educational and quality improvement purposes, we will be maintaining a Data Repository of all submitted case presentation forms. By submitting this form, you are consenting to the ECHO Institute collecting and housing your case presentation form.

Please email CancerSurvivorshipECHO@salud.unm.edu if you have any questions regarding this form.

Program Email

* must provide value

Date

* must provide value

M-D-Y

First Name:

* must provide value

Last Name:

* must provide value

Email Address:

* must provide value

Organization:

* must provide value

Primary Insurance:

* must provide value

Name of Medicaid:

* must provide value

Secondary Insurance:

* must provide value

Name of Medicaid:

* must provide value

Age:

* must provide value

Gender Identity:

* must provide value

If Other, please explain:

Sex at Birth:

* must provide value

Race/Ethnicity:

* must provide value

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Hispanic, Latino, or Spanish

White

Some other race, ethnicity, or origin

Prefer not to disclose

What are the patient's primary concerns reported during Survivorship?

* must provide value

Cardiac health

Anxiety/Depression

Cognitive function

Fatigue

Lymphedema

Hormone-related symptoms

Pain

Family

Sexual function

Sleep disorder

Healthy lifestyle

Immunizations

Employment/Return to work

Other

What are your primary concerns regarding this patient?

* must provide value

Expand

Chemotherapy:

* must provide value

Yes

reset

Radiation Therapy:

* must provide value

Yes

reset

Immunotherapy:

* must provide value

Yes

reset

Surgery:

* must provide value

Yes

reset

Hormonal Therapies:

* must provide value

Yes

reset

Treatment Status:

* must provide value

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.