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!
* Required
Email address
*
Your email
Name of Insurance Company
*
Choose
MODA
Blue Cross Blue Shield
Aetna
Cigna
Providence
United
First Choice Health
Samaritan
Pacific Source
Other
Name (First & Last)
*
Your answer
Are you 18 years of age or older?
*
Yes
No
Have you ever been diagnosed with or treated for Obsessive Compulsive Disorder?
Yes
No
Unsure
Have you ever been diagnosed with or treated for depression?
*
Yes
No
Unsure
How many antidepressant medications have you tried?
*
none
1
2
3
4 or more
Have you tried psychotherapy/counseling?
*
Yes
No
Do you have a metal implant in or around your head (not including metal fillings in teeth)?
*
Yes
No
Have you ever had a seizure or been diagnosed with a seizure disorder?
*
Yes
No
Have you tried TMS therapy?
*
Yes
No
If you previously tried TMS, was it helpful?
Not at all helpful
1
2
3
4
5
Very helpful
Have you ever been diagnosed or treated for Bipolar Disorder, Schizoaffective Disorder, or Schizophrenia?
*
Yes
No
Unsure
Have you ever been told you have a personality disorder (e.g. Borderline Personality Disorder)?
*
Yes
No
Unsure
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
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
If it's ok for us to follow up with you by phone please leave your phone number here (we won't share it with anyone!)
Your answer
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