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.
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Email *
Name *
Date of Birth *
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Address
City
State *
Zip / Postal Code
Phone
Tell us about your experience with ECT
Date of Last ECT *
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Date of First ECT *
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In which state was your ECT administered? *
Approximate number of ECTs received *
Was your ECT Treatment:
Clear selection
Name of ECT Device Manufacturer (if known)
Name of Clinic/Hospital and City where ECT performed *
Name of Healthcare Provider who referred you to ECT *
Name of Healthcare Provider who Administered the ECT *
Reason for ECT Treatment:  (check all that apply) *
Required
Were you employed prior to your first ECT Treatment? *
If Yes, What date were you last employed prior to your first ECT Treatment?
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... What was your occupation and annual earnings prior to ECT?
Has your employment been affected by your post-ECT complaints?
Clear selection
 If Yes, Please describe the nature and extent of how your ECT related injuries has affected your employment
Has your post-ECT complaints affected your ability to obtain employment?
Clear selection
If Yes, Please describe how your ECT related injuries has hindered your ability to obtain employment
What is the highest level of education/any degrees you received?
At the time of your ECT treatment(s), did you have private health insurance? *
If Yes, which carrier?
If No, what insurance did you have at the time of your ECT treatment(s)?
Clear selection
Provide all health insurance you have had since your last ECT treatment
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? *
If Yes, Have you ever been convicted of a felony?
Clear selection
If Yes, please explain:
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: *
Did you ever have any of these complaints prior to ECT? *
If Yes, please explain:
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, MRI, or any other testing or evaluation done after ECT to assess your lingering complaints? *
If Yes, What testing or evaluation has been done to assess your lingering complaints after ECT?
 ... Who performed the testing/evaluation?
 ... What Date(s) were any Post-ECT tests performed?
At least 1 month after your last ECT treatment, 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?
 ... What date were you first advised that ECT may have caused your lingering complaints?
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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?
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 ... What reasons were you told were other potential causes of your post-ECT lingering complaints?
How did you learn about the link between ECT treatment and injuries (i.e., memory loss, brain damage, cardiovascular, cognitive, etc.)? *
When did you learn about this link between ECT treatment and injuries? (If you need to approximate, narrow down as much as possible. Examples: February 2008, Summer 2010, Thanksgiving 2015) *
Have you ever read or heard anything on internet websites (including chat rooms, blogs, or any other electronic media) about post-electroshock treatment injury (i.e. memory loss, brain damage, cognitive impairment, etc.)? *
If Yes, When?
... Website:
... What program / show?
... Details of info given:
19. Have you ever seen any television advertisements about post-electroshock treatment injury (i.e. memory loss, brain damage, cognitive impairment, etc.)? *
If Yes, When?
... Channel:
... Name of program / show:
... Details of info given:
Have you ever heard any radio shows about post-electroshock treatment injury (i.e. memory loss, brain damage, cognitive impairment, etc.)? *
If Yes, When?
... What station?
... Name of program / show:
... Details of info given:
Have you ever discussed with the manufacturer of the ECT device, American Psychiatric Association, FDA, or other entity or organization your post-electroshock treatment injury (i.e. memory loss, brain damage, cognitive impairment, etc.)? *
If Yes, When?
... With whom?
... Details of conversation:
Have you ever discussed with any person (i.e. friend, family, doctor, etc.) post-electroshock treatment injury (i.e. memory loss, brain damage, cognitive impairment, etc.)? *
If Yes, When?
... Person:
... Relation:
... Details of conversation:
Did you perform any other type of investigation (i.e. internet research, library research, contact an attorney, etc.) to determine the link between post-electroshock treatment and injuries (i.e. memory loss, brain damage, cognitive impairment, etc.)? *
If Yes, When?
... Type (i.e., internet, library, contact lawyer):
... Information obtained:
... Name of lawyer or law firm:
... Details of conversation:
Have you ever been involved in any CLINICAL TRIAL or RESEARCH STUDY regarding post-electroshock treatment injury (i.e. memory loss, brain damage, cognitive impairment, etc.)? *
Is there any other pertinent ECT related history you believe is important for us to know?
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