Get Canada St Michael's Hospital Autoimmune Encephalitis Panel Questionnaire - Cover Sheet

Completing the Canada St Michael's Hospital Autoimmune Encephalitis Panel Questionnaire - Cover Sheet is a crucial step in the process of ordering the autoimmune encephalitis panel. This guide provides clear, step-by-step instructions to assist you in accurately filling out the form online.

Follow the steps to fill out the cover sheet accurately.

1. Click 'Get Form' button to obtain the form and open it in your preferred online editing tool.
2. Begin by entering the patient’s full name in the designated field, ensuring to include both the last and first names.
3. Fill in the patient’s date of birth following the format DD/MM/YYYY, which helps in accurate identification.
4. If applicable, enter the Patient Identification Number or Medical Record Number for LHSC/SJHC patients.
5. Complete the referring physician's information by filling in their name, email, and phone number. This ensures that communication regarding the panel can be efficiently conducted.
6. Indicate the sample type by checking the appropriate box for either serum or CSF, and include the sample collection date in the specified format (DD/MM/YY).
7. Provide the patient's demographic information including age, sex, and ethnicity to give a comprehensive picture of the patient.
8. Detail any relevant past medical history by checking 'Yes' or 'No', and if applicable, note any diagnosed conditions.
9. Answer the questions related to the patient's neurological/psychiatric history, and include information regarding family history of autoimmunity.
10. Document any presence of malignancy, preceding infections, and diagnostic tests performed that are relevant to the patient's condition.
11. Fill out the clinical course, including symptomology and disease progression as it provides critical context for analysis.
12. Gather information on any investigations performed such as MRI, EEG, or lumbar puncture and indicate relevant results.
13. Detail suspected diagnoses and provide possible antibody suspects, which will guide further testing.
14. Complete the patient symptomatology checklist by marking 'Yes' or 'No' as applicable for various symptoms, while elaborating where needed.
15. Once all sections are filled out, review the information for accuracy before saving, downloading, printing, or sharing the form.

Complete your documents online to ensure accurate processing of the autoimmune encephalitis panel.