TMS Self-Assessment
Please complete the questions below to the best of your ability. The information on this form is strictly confidential. Once you have completed this form, our office will contact you in regards to the next steps. Thank you!
Email *
Name (First & Last) *
Date of Birth *
Name of Insurance Company *
Have you ever been diagnosed with or treated for Obsessive Compulsive Disorder?
Clear selection
Have you ever been diagnosed with or treated for depression? *
How many antidepressant medications have you tried? *
Have you tried psychotherapy/counseling? *
Do you have a metal implant in or around your head (not including metal fillings in teeth)? *
Do you have any electrical implants (e.g. pacemaker)? *
Have you ever had a seizure or been diagnosed with a seizure disorder? *
Have you tried TMS therapy? *
If you previously tried TMS, was it helpful?
Not at all helpful
Very helpful
Clear selection
Have you ever been diagnosed or treated for Bipolar Disorder, Schizoaffective Disorder, or Schizophrenia? *
Have you ever been told you have a personality disorder (e.g. Borderline Personality Disorder)? *
Over the last two weeks, how often have you been bothered by any of the following problems? *
0 - Not At All
1 - Several Days
2 - More than Half of the Days
3 - Nearly Every Day
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 better off dead or hurting yourself in some way
Phone number for us to follow up with you (we won't share it with anyone!)
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