Informed Consent

1. PURPOSE: The purpose of this form is to obtain your consent to participate in mental health services, telehealth and other Operation Vet Fit consultations in connection with the following procedure(s) and/or service(s): Health, Behavioral and Therapy Services Support via TELEHEALTH, including streaming video and audio feeds, with recording and in person activities. 2. NATURE OF TELEHEALTH CONSULT: During the telehealth consultation: a. Details of your medical history, examinations, x-rays, and test will be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology. b. A physical examination of you may take place. c. A non-medical technician may be present in the telehealth studio to aid in the video transmission. d. Video, audio and/or photo recordings may be taken of you during the procedure(s) or service(s) 3. MEDICAL INFORMATION & RECORDS: All existing laws regarding your access to medical information and copies of your medical records apply to this telehealth consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient- identifiable images or information for this telehealth interaction to researchers or other entities shall not occur without your consent. 4. CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telehealth consultation, and all existing confidentiality protections under federal and SC state law apply to information disclosed during telehealth and other consultation. 5. RIGHTS: You may withhold or withdraw consent to the telehealth or other consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. 6. DISPUTES: You agree that any dispute arriving from the telehealth consult will be resolved in SC and SC law shall apply to all disputes. 7. RISKS, CONSEQUENCES & BENEFITS: You have been advised of all the potential risks, consequences and benefits of telehealth. Your health care practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telehealth consultation. All your questions have been answered, and you understand the written information provided above. I agree to participate in a telehealth and in-person consultation for the procedure(s) described above.

PHQ-9: In the last 30 days are you bothered by any of the following problems?

1. Having little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling asleep or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

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

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

8. 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

9. Thoughts that you would be better off dead or of hurting yourself in some way

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

1. Not at all difficult 2. Somewhat difficult 3. Very difficult 4. Extremely difficult

GAD-7 In the last 30 days are you bothered by the following ?

1. Feeling nervous, anxious, or on edge?

2. Not being able to stop or control worrying?

3. Worrying too much about different things

4. Trouble relaxing?

5. Being so restless that it is hard to sit still?

6. Becoming easily annoyed or irritable?

7. Feeling afraid as if something awful might happen?

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

1. Not at all difficult 2. Somewhat difficult 3. Very difficult 4. Extremely difficult

Universal Pain Assessment Tool:

What is your current level of pain?

0-1 No Pain 2-3 Mild Pain, can be ignored 3-4 Moderate Pain, interferes with tasks 5-6 Moderate Pain, interferes with concentration 7-8 Severe Pain, interferes with basic needs 9-10 Worst Pain Possible, bedrest required

Officer or Enlisted

If you served in the Armed Forces, were you an officer or were you enlisted. Or both?

Do you currently have a rating for PTSD

If you have a PTSD rating or believe you may have PTSD

Education Level