Project ECHO- Cervical Cancer Prevention case template Instructions to fill out this template All participants must comply with HIPPA regulations and not use any Patient Identifiers when submitting cases for review Please briefly describe relevant aspects of your case and draft your question (s) at the end of the presentation Pictures are welcome but not necessary Send this form before the next ECHO clinic so the facilitators have some time to review your case and provide valuable feedback Email your completed form to mslopez1@mdanderson.org and cc CEAmos@mdanderson.org Be advised that this ECHO consultation does not create or otherwise establish a provider-patient relationship between any MD Anderson clinician and any patient whose case is being presented in a Project ECHO setting

Project ECHO- Cervical Cancer Prevention case template Presenter’s name: Clinical Site: Role/ Title Patient’s age: Gender: Type of services provided (select): Office, Home or community, phone, other Diagnoses: Assigned case # by ECHO team:

History Chief complaint of the patient: Problems (List any problems from the list on slide 4): Significant past medical surgical: Medications: Allergies: Psycho-social-spiritual history Ease to access healthcare/ utilization for the Patient Family tree and support

ESAS (0-10 scale, 0=no symptom; 10 worst possible symptom in last 24 hours Pain 1 2 3 4 5 6 7 8 9 10 or Did not assess Fatigue Nausea Depression Anxiety Drowsiness Shortness of breath Appetite Feeling of bell-being Sleep/ other symptom

Physical Exam Temperature: Blood pressure: Pulse: Respiratory Rate: O2 saturation: ECOG performance status: (0= nl; 1=some symptoms; 2= in bed / chair less than 50% of time; 3= bed and chair greater than 50%; 4= confined to bed, no self care): 0-1-2-3-4 Pertinent findings:

Labs and Imaging Please add pertinent labs (with normal values –ranges) images if any relevant

Assessment and Patient defined Goals of Care What is important to the patients and their family?

Questions/ Discussion Please state your questions for the ECHO team Please describe what you would like the team to help you with