Intrathecal Pump/SCS Evaluation

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NIDA QUICK SCREEN - In the past year, how many times have you used the following?

In your LIFETIME, which of the following substances have you ever used?

Chronic Pain Assessment Questionnaire - Pain is a patient-specific experience that requires ongoing assessment and evaluation, both by patients and their providers. This questionnaire will help assess the two parts of chronic pain that often change over time, persistent baseline and breakthrough pain. Please take a moment to complete this questionnaire.

Part 1: Assessment of Persistent Baseline Pain

If Severe, your baseline pain may be uncontrolled; please continue to the next step and discuss with your physician who may adjust your baseline treatment as needed.

If Mild or Moderate, your baseline pain is controlled. Please proceed to the next question.

4. Assess the nature of your baseline pain

Part 2: Assessment of Breakthrough Pain

If yes, complete questions 12 and 13. If no, please skip the remaining questions in this section.

PATIENT HEALTH QUESTIONNAIRE (PHQ-9) - This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question to the best of your ability.

Over the last 2 weeks, how often have you been bothered by any of the following problems?

If you checked off any problems on this questionnaire, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

WEST HAVEN-YALE MULTIDIMENSIONAL PAIN INVENTORY (WHYMPI) - BEFORE YOU BEGIN, PLEASE ANSWER 2 PRE-EVALUATION QUESTIONS BELOW:

When you answer the following questions about "your significant other", always respond in reference to the specific person you just indicated above.

A. In the following 20 questions, you will be asked to describe your pain and how it affects your life. Under each question is a scale to record your answer. Read each question carefully and then pick a number on the scale under that question to indicate how that specific question applies to you.

B. In this section, we are interested in knowing how your significant other (this refers to the person you indicated above) responds to you when he or she knows that you are in pain. On the scale listed below each question, choose a number to indicate how often your significant other generally responds to you in that particular way when you are in pain.

C. Listed below are 18 common daily activities. Please indicate how often you do each of these activities by choosing a number on the scale listed below each activity. Please complete all 18 questions.

The DASS 21 is a 21 item self-report questionnaire designed to measure the severity of a range of symptoms common to depression, anxiety and stress. While completing the DASS, you are required to indicate the presence of a symptom over the previous week.
Please read each statement and click the circle next to how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures or surgery.

Instructions:
We are interested in the types of thoughts and feelings that you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain. Using the following scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain.

Informed Consent for Telehealth Services

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered by Behavioral Health Specialists (BHS) may also include chart review, remote prescribing, prescription refills, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio-video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.BHS physicians and other healthcare professionals (our "providers") are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.

Expected Benefits:

• Improved access to care by enabling you to remain in your home while the BHS provider consults and obtains test results at distant/other sites.
• More efficient care evaluation and management.
• Obtaining expertise of a specialist as appropriate.

Possible Risks: 

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
• In rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
• In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
• In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact BHS at (877) 583-5633.

By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:

1. I hereby consent to receiving BHS's services via telehealth technologies. I understand that BHS and its providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the BHS provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
2. I have been given an opportunity to select a provider from BHS prior to the consult, including a review of the provider's credentials.
3. I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that BHS will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.
4. I understand there is a risk of technical failures during the telehealth encounter beyond the control of BHS. I agree to hold harmless BHS for delays in evaluation or for information lost due to such technical failures.
5. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the BHS providers are not able to connect me directly to any local emergency services.
6. I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the BHS provider (e.g. labs or diagnostics).
7. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
8. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the BHS provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
9. I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.
10. I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
11. I will not audio or video record the telehealth consultation, although I may take still photographs to document clinical pathology.

Patient Consent

I have read this document carefully, and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telehealth consultation under the terms described herein. 

By checking the Box containing “I CONSENT TO USING TELEHEALTH SERVICES” I hereby state that I have read, understood, and agree to the terms of this document.

Congratulations. You have completed your registration and online assessment. The next step is to register on the patient portal to schedule your interview.