WVCTSI Project ECHO
Hepatitis C
SUD
Psychiatry
Chronic Lung Disease
HIV
Endo
Campus Mental Health
COVID-19
PPW SUD
Statewide Antimicrobial Stewardship
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.
HIV Case Presentation Form
Presentation Date
Popup Calendar: Presentation Date
Clinic Site
Site Contact Email Address
Clinician
General Information / Demographics
Visit Date
Popup Calendar: Visit Date
Age
Gender
M
F
Bi
Trans M+F
Trans F+M
Ethnicity Hispanic Latino
Y
N
Race
American Indian / Alaska Native
Asian
Black / African American
Native Hawaiian / Pacific Islander
White
Insurance
None
Medicare
Medicaid / MCO
Commercial Health Insurance
Other
Insurance Other
Case Presentation
HPI and Social History
Comorbidities
Relevant Physical Exam and Lab Results
All Medications
Risk factors for HIV Infection/Transmission
Risk Factors (Please check all that apply.)
Risk Factors (Please check all that apply.)
Currently sexually active
History of other STDs
Occupational Exposures
Perinatal
Shared Hypodermic Needles
Tattoos/Piercings
Trades sex for money/drugs/other things
Transfusions
Uses condom every time during sex
Sexual Partners / Preference
Male
Female
Both
Are your sexual partners aware of HIV status?
Y
N
Have your partners been tested?
Y
N
Don't Know
Are they interested in PrEP?
Y
N
Please provide any additional information about risk factors:
Labs
CD4
HIV viral load
HIV genotype
Positive
Negative
(if positive please upload below)
HIV Integrase Genotype
HLA-B 5701 genotype for abacavir sensitivity
Genotype File Upload Notice
You chose HIV genotype positive above, please upload your file in the next section
HIV Genotype File Upload
Upload New File
No files uploaded
Vaccinations
Vaccines:
Questions
What are the main questions you have about this case?
Upload a file relevant to the case (optional)
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Submit
Instructions
If you have any questions regarding the ECHO project, please send an email to
Jay Mason
,
Mithra Mohtasham
, or
Elisabeth Minnick
.