ECT Questionnaire
Please fill out this form to the best of your ability.
Your Name
First
Your answer
Last
Your answer
What state/province/country do you reside in?
Your answer
I am
How can we contact you?
A valid email address or phone number is required.
Email Address
Your answer
Phone
Your answer
Tell us about your experience with ECT.
On what dates did you receive ECT?
Your answer
What state (or province & country) was your ECT performed in?
Your answer
At what facilities did you receive ECT?
Your answer
What is the name of the doctor who gave you ECT?
Your answer
How many ECT treatments did you receive?
Your answer
What effect did ECT have on you?
Your answer
When did you notice the effects of ECT?
Your answer
Are any of the ECT effects permanent?
Your answer
List the names of family or friends who witnessed the effect ECT had on you.
Your answer
Do you have any medical records or documents relating to your ECT or its effects?
Your answer
Please describe, in as much detail as possible, your life before ECT and what led you to undergo ECT.
Your answer
Is there anything else you'd like to communicate?
Your answer
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