HIT Consultation Request Form

Email address*
example@example.com
We currently conduct 15-minute consults on Mondays between 2:00 pm and 3:00 pm (Central Time). What is your preferred Monday date?

MonthDayYear
Click to view a calendar
Does this case require urgent input (e.g., prior to the weekly case discussion)?*

YesNoOther
Requestor Information
Location*
Requested by Name*

First NameLast Name
Institution*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Fax (US submitters: Please add the clinic fax where notifications will be sent)*
Please enter a valid phone number.
Patient Information
Name*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Please enter patient's birthdate
Gender assigned at birth*

MaleFemale
Ethnicity*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of presentation*
Reason for consultation*
Is the patient:*

In-patientOut-patient
If in-patient, are they in the ICU?

YesNo
History of present Illness
Please describe key symptoms and findings such as:
- Fever duration and pattern
- Rash, joint swelling, organ enlargement
- Lymphadenopathy, serositis, etc.
Enter text below
Past medical history
Prior Diagnoses / Concerns:
- Known malignancies
- Autoimmune or rheumatologic diseases
- Recurrent infections
- Previous hospitalizations
- Growth/developmental concerns
Enter text below
Family and Social History
Family History:
- Early deaths, suspected immune disorders, malignancies
Enter text below
Social/Exposure History
- Daycare/school attendance
- Vaccination history + complications
- Animal exposures
- Travel in past year
Enter text below
Past medical history
Family and social history (include number of siblings, family relationships)
Diagnostic Workup
Please enter diagnostic workup data below.
CBC (include date/s)*
Bone marrow findings, i.e., cellularity, morphology, cytogenetics, FISH, immunophenotyping (include date/s and UPLOAD THE ORIGINAL REPORT/S)*

Chemistry

	Value
Na
CO2
Cr
AST
ALT
Total Bili
Direct Bili
LDH
TG

Coagulation Panel

	Value
PTT
INR
Fibrinogen

Inflammatory Markers

	Value
Ferritin
Procalcitonin
CRP
Cytokine panel (including, sIL-2R, if available)

Microbiology

	List below
Cultures
Serologies
PCRs
Other

Other relevant workup (Iron studies, B12, Folate, Coombs, peripheral smear, etc.)
Bone marrow findings, i.e., cellularity, morphology, cytogenetics, FISH, immunophenotyping (include date/s and upload report)

HLH-specific functional/expression testing or immune-deficiency testing

	Yes	No
Perforin expression (upload)
CD107a mobilization (upload)
SAP/XIAP expression (upload)

Other work-up (e.g., immunoglobulin levels, lymphocyte subsets, etc.)
Relevant imaging studies (include date/s; upload report if possible)
Please upload relevant diagnostic documents (pdf) or images (maximum size for an individual file is 1GB; maximum number of uploads allowed is 25)

Cancelof
Treatment and Disease Evolution

Initial, previous, and current therapy (includedate ranges)
Immunomodulators and immunosuppressive agents (including IVIG and steroids) and Chemotherapy (if received)
Previous and current infectious diseases treatment
Other treatment(s)/intervention(s)
Please provide any additional necessary information
Should be Empty:

Requestor Information

Patient Information

History of present Illness

Past medical history

Family and Social History

Past medical history

Diagnostic Workup

Please enter diagnostic workup data below.

Treatment and Disease Evolution