1. Interval Post Operative Retention of Key Portions of the Informed Consent Discussion in the Adult Deformity Patient IRB Approval Date:

2. For spinal deformity patients who have agreed to participate in the informed consent study

3.  This video is for research purposes only.  It does not take the place of a consent form.  The complications listed are the more common complications but this is not included every complications you might experience.  Please talk to your physician if you have any questions.  Please talk to your physician if you have questions about this video or the risks discussed or any additional questions about this procedure.

4.  How important do you think the informed consent process is on a scale of 1-10 with 10 being most important?  1 2 3 4 5 6 7 8 9 10

5.  Infection (2-5%)  Inadequate pain relieve or new pain (5-20%)  Need for more surgery (15-25%)  Medical complications (10-20%)  Weakness (5-10%)  Skin or muscle or nerve positioning complication (2-5%)  Instrumentation malposition (.5-20%)  CSF leak (2-10%)  Bleeding that requires transfusion (50-75%)  Death (.5-2%)  Blindness ( less than 1%)

6. Rate 2-5%

7. (5-20%)

8. (15-25%)

9. (10-20%)

10. (Approx 5-10%)

11. (2-5%)

12. (.5-20%)

13. (2-10%)

14. (50-75%)

15. ( less than 1%)

16. (.5-2%)

17.  Infection (2-5%)  Inadequate pain relieve or new pain (5-20%)  Need for more surgery (15-25%)  Medical complications (10-20%)  Weakness (5-10%)  Skin or muscle or nerve positioning complication (2-5%)  Instrumentation malposition (.5-20%)  CSF leak (2-10%)  Bleeding that requires transfusion (50-75%)  Death (.5-2%)  Blindness ( less than 1%)

18.  How well informed do you feel now after the consent process on a scale of 1-10 with 10 being very well informed and 1 being not well informed at all?  1 2 3 4 5 6 7 8 9 10

19.  How important do you think the informed consent process is on a scale of 1-10 with 10 being most important?  1 2 3 4 5 6 7 8 9 10

20.  How much did the slide show help on a scale of 1-10 with 10 being most helpful and 1 not helpful at all?  1 2 3 4 5 6 7 8 9 10

21.  What do you think is your risk of experiencing one of these complications?  0%  10%  20%  30%  40%  50%  60%  70%  80%  90%  100%

22.  11 possible risks of my surgery are:  _____________________

23.  Recall common or uncommon  Is this a major or minor complication

24.  Common  Rare  1 Minor  2  3  4  5  6  7  8  9  10 Very severe

25.  Common  Rare  1 Minor  2  3  4  5  6  7  8  9  10 Very severe

26.  Common  Rare  1 Minor  2  3  4  5  6  7  8  9  10 Very severe

27.  Common  Rare  1 Minor  2  3  4  5  6  7  8  9  10 Very severe

28.  Common  Rare  1 Minor  2  3  4  5  6  7  8  9  10 Very severe

29.  Common  Rare  1 Minor  2  3  4  5  6  7  8  9  10 Very severe

30.  Common  Rare  1 Minor  2  3  4  5  6  7  8  9  10 Very severe

31.  Common  Rare  1 Minor  2  3  4  5  6  7  8  9  10 Very severe

32.  Common  Rare  1 Minor  2  3  4  5  6  7  8  9  10 Very severe

33.  Common  Rare  1 Minor  2  3  4  5  6  7  8  9  10 Very severe

34.  Common  Rare  1 Minor  2  3  4  5  6  7  8  9  10 Very severe

35.  Infection (2-5%)  Inadequate pain relieve or new pain (5-20%)  Need for more surgery (15-25%)  Medical complications (10-20%)  Weakness (5-10%)  Skin or muscle or nerve positioning complication (2-5%)  Instrumentation malposition (.5-20%)  CSF leak (2-10%)  Bleeding that requires transfusion (50-75%)  Death (.5-2%)  Blindness ( less than 1%)

36.  This video is for research purposes only.  It does not take the place of a consent form.  The complications listed are the more common complications but this is not included every complications you might experience.  Please talk to your physician if you have any questions.  Please talk to your physician if you have questions about this video or the risks discussed or any additional questions about this procedure.