ECT Questionnaire
The purpose of this questionnaire is to seek information only and does not bind you to participate in any litigation.

CONFIDENTIALITY: The information provided on this form is attorney-client privilege and confidential.
TRUTHFULNESS: Please answer the questions honestly and to the best of your ability. If you do not know the answer, you may estimate or give approximations, but please do not guess.

Email address *
Name *
Your answer
Date of Birth *
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Address
Your answer
City
Your answer
State *
Your answer
Zip / Postal Code
Your answer
Phone
Your answer
Tell us about your experience with ECT
Date of Last ECT *
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DD
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YYYY
Date of First ECT *
MM
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DD
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In which state was your ECT administered? *
Your answer
Approximate number of ECTs received *
Your answer
Was your ECT Treatment:
Name of ECT Device Manufacturer (if known)
Your answer
Name of Clinic/Hospital and City where ECT performed *
Your answer
Name of Healthcare Provider who referred you to ECT *
Your answer
Name of Healthcare Provider who Administered the ECT *
Your answer
Reason for ECT Treatment: (check all that apply) *
Required
Has your employment been affected by your post-ECT complaints? *
If Yes, What was your occupation and annual earnings prior to ECT?
Your answer
... Please describe the nature and extent of any impact on your employment and earnings
Your answer
What is the highest level of education/any degrees you received?
Your answer
At the time of your ECT treatment(s), did you have private health insurance? *
If Yes, which carrier?
Your answer
If No, what insurance did you have at the time of your ECT treatment(s)?
Provide all health insurance you have had since your last ECT treatment
Your answer
Had you ever experienced brain trauma/injury prior to ECT? *
If Yes, what did you experience?
Have you ever had a brain tumor (whether or not benign)? *
Have you ever used illicit, mind-altering /hallucinogenic drugs? *
Have you ever been convicted of a felony? *
If Yes, please explain:
Your answer
Please provide a summary of your post-ECT cognitive or behavioral complaints and duration that has continued at least a month after your last ECT treatment: *
Your answer
Did you ever have any of these complaints prior to ECT? *
If Yes, please explain:
Your answer
Did you ever report these lingering complaints to a healthcare provider at least a month after your last ECT treatment? *
If YES, what date did you first report any lingering complaints after ECT?
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Have you had any neuropsychology testing done after ECT to assess your lingering complaints?
Have you had any type of evaluation done to assess your lingering complaints after ECT? *
If Yes, What testing or evaluation has been done to assess your lingering complaints after ECT?
Your answer
... Who performed the testing?
Your answer
... What Date(s) were any Post- ECT tests performed?
Your answer
Has any healthcare provider ever advised you that your post-ECT lingering complaints may have been caused by ECT? *
If Yes, Which Healthcare provider(s) advised you your lingering complaints were possibly attributed to ECT?
Your answer
... What date were you first advised that ECT may have caused your lingering complaints?
MM
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YYYY
If no Healthcare provider has ever advised you that your post-ECT lingering complaints may be caused by ECT, on what date did you first believe your post-ECT complaints may be caused by ECT?
MM
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... Why do you believe that your post-ECT lingering complaints may be caused by ECT?
Your answer
Were you ever advised by a healthcare provider that there were other reasons for your post-ECT lingering complaints?
If Yes, What date were you advised that there were other reasons for your post-ECT lingering complaints?
MM
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DD
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YYYY
... What reasons were you told were other potential causes of your post-ECT lingering complaints?
Your answer
Is there any other pertinent ECT related history you believe is important for us to know?
Your answer
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