Spinal Fusion/Laminectomy Evaluation

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
DASS-21
Pain Catastrophizing Scale
The Alcohol Use Disorders Identification Test
NIDA QUICK-SCREEN
Chronic Pain Assessment Questionnaire
Informed Consent for Telehealth Services

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:

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.
I have been given an opportunity to select a provider from BHS prior to the consult, including a review of the provider's credentials.
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.
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.
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.
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).
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.
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.
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.
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.
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.

I CONSENT TO USING TELEHEALTH SERVICES

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

Spinal Fusion/Laminectomy Evaluation

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

NAME--AUTOFILL

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself - or that you are a failure or have let yourself or your family down

Trouble concentrating on things, such as reading the newspaper or watching television

Moving or speaking so slowly that other people could have noticed. Or, the opposite - being so fidgety or restless that you have been moving around a lot more than usual

Thoughts that you would be beter off dead of or hurting yourself in some way

Thoughts that you would be beter off dead of or hurting yourself in some way

DASS-21

I found it hard to wind down

I was aware of dryness of my mouth

I couldn't seem to experience any positive feeling at all

I experienced breathing difficulty (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion)

I found it difficult to work up the initiative to do things

I tended to over-react to situations

I experienced trembling (e.g. in the hands)

I felt that I was using a lot of nervous energy

I was worried about situations in which I might panic and make a fool of myself

I felt that I had nothing to look forward to

I found myself getting agitated

I found it difficult to relax

I felt down-hearted and blue

I was intolerant of anything that kept me from getting on with what I was doing

I felt I was close to panic

I was unable to become enthusiastic about anything

I felt I wasn't worth much as a person

I felt that I was rather touchy

I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat)

I felt scared without any good reason I felt that life was meaningless

Pain Catastrophizing Scale

I worry all the time about whether the pain will end.

I feel I can't go on.

It's terrible and I think it's never going to get any better

It's awful and I feel that it overwhelms me.

I feel I can't stand it anymore

I become afraid that the pain will get worse.

I keep thinking of other painful events

I anxiously want the pain to go away

I can't seem to keep it out of my mind

I keep thinking about how much it hurts.

I keep thinking about how badly I want the pain to stop

There's nothing I can do to reduce the intensity of the pain

I wonder whether something serious may happen.

The Alcohol Use Disorders Identification Test

How often do you have a drink containing alcohol?

How many drinks containing alcohol do you have on a typical day when you are drinking?

How often do you have six or more drinks on one occasion?

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected of you because of drinking?

How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you had a feeling of guilt or remorse after drinking?

How often during the last year have you been unable to remember what happened the night before because of your drinking?

Have you or someone else been injured because of your drinking?

Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

NIDA QUICK-SCREEN

Alcohol -For Men more than 5 drinks a day -For Women more than 4 drinks a day

Tobacco products

Prescription Drugs for Non-Medical Reasons

Illegal drugs

Cannabis (marijuana, pot, grass, hash, etc.)

Cocaine (coke, crack, etc.)

Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)

Methamphetamine (speed, crystal meth, ice, etc.)

Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)

Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium,Rohypnol, GHB, etc.)

Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)

Street opioids (heroin, opium, etc.)

Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) ? Please record nonmedical use only: Non-medical use refers to using a substance either not prescribed to the patient or used in ways or amounts not prescribed by their doctor.

Other ? specify:

Chronic Pain Assessment Questionnaire

1. During the past week, have you had any pain or would you have had pain if not for the treatment you are receiving?

2. Is this pain present continuously (most of the day) on most days or would the pain persist if not for the treatment you are receiving?

3. During the past week, on average, how would you rate your baseline pain on a scale of 0 to 10?

Where do you feel this pain? (Refer to the following figure.) Describe and list all the numbers associated with the areas you feel this pain.

How long have you experienced this pain (in weeks)?

Alcohol
-For Men more than 5 drinks a day
-For Women more than 4 drinks a day