Disclosure Statement

PLEASE NOTE that Project ECHO® case consultations do not create or otherwise establish a provider-patient relationship between any WVU clinician and any patient whose case is being presented in a Project ECHO setting. Always use ECHO ID# when presenting a patient in clinic. Sharing patient name, initials or other identifying information violates HIPAA privacy laws.

Chronic Pain Case Presentation Form

General Information / Demographics

Case Presentation

Please describe your patient and be ready to answer follow-up questions. Remember to not use any patient identifying information.

WVU Medicine Pain Rating Scale Information

Select the one number that describes how, during the past 24 hours, pain has interfered with your:
 
<strong>Activity</strong>
(1=Doesn't interfere   <--->  10=Completely interferes)
<strong>Sleep</strong>
(1=Doesn't interfere   <--->  10=Completely interferes)
<strong>Mood</strong>
(1=Doesn't affect   <--->  10=Completely affects)
<strong>Stress</strong>
(1=Doesn't contribute <---> 10=Contributes a great deal)
<strong>Overall</strong>
(1=No Pain <---> 10=Severe Pain)

Questions

Instructions

If you have any questions regarding the ECHO project, please send an email to Jay Mason, Mithra Mohtasham, or Elisabeth Minnick.