NSTMS - Followup Appointment Assessment

NeuroScience & TMS Treatment Centers

Assessments for Existing Patients Follow-up appointments
These Assessments help us to help track your physical and emotional symptoms. This is helpful for you, and our care for you. It is a way for us to assess how well we are helping you.
Name *

First Name Initial of Last Name
Automatic PHQ-9* Calculation
This will populate automatically after you complete the form in its entirety.
Automatic Q9 of PHQ* Calculation
This will populate automatically after you complete the form in its entirety.
Automatic GAD-7* Calculation
This will populate automatically after you complete the form in its entirety.
Your Email address *
example@example.com
Which Clinician are you seeing in the office for your care? *

Brentwood Office - Psychiatrist, Jonathan Becker, DO Brentwood Office - Psychiatric Nurse Practitioner, Mary Phillips, APRN Brentwood Office - Psychiatric Nurse Practitioner, Susan Swanson-Moore, APRN Brentwood Office - Psychiatrist, Michelle Cochran, MD Brentwood Office - Ali Self, LMSW Nashville Satellite Offfice - Psychiatrist, Michelle Cochran, MD
Q1. Over the last 14 days (2 weeks), how often have you been bothered by feeling down, depressed, sad, tearful, and/or hopeless *

Not at all Up to several days Half of the days Nearly everyday
Q2. Over the last 14 days (2 weeks), how often have you been bothered by trouble falling asleep, staying asleep, waking up too early, OR sleeping too much? *

Not at all Up to several days Half of the days Nearly everyday
Q3. Over the last 14 days (2 weeks), how often have you been bothered by little interest or pleasure in doing things? *

Not at all Up to several days Half of the days Nearly everyday
Q4.Over the last 14 days (2 weeks), how often have you been bothered by feeling worthless, hopeless, helpless, guilty, and/or like a failure? *

Not at all Up to several days Half of the days Nearly everyday
Q5. Over the last 14 days (2 weeks), how often have you been bothered by low energy, feeling tired, or fatigued? *

Not at all Up to several days Half of the days Nearly everyday
Q6. Over the last 14 days (2 weeks), how often have you been bothered by trouble with concentration (watching TV, reading, work) indecisiveness, and/or trouble maintaining focus? *

Not at all Up to several days Half of the days Nearly everyday
Q7. Over the last 14 days (2 weeks), how often have you been bothered by poor appetite or overeating? *

Not at all Up to several days Half of the days Nearly everyday
Q8. Over the last 14 days (2 weeks), how often have you been bothered by moving or speaking so slowly that other people could have noticed; OR, the opposite, feeling so fidgety or restless that you’ve been moving around more? *

Not at all Up to several days Half of the days Nearly everyday
Q9. Over the last 14 days (2 weeks), how often have you been bothered by thoughts that you would be better off dead or thoughtsof hurting yourself in some way? *

Not at all 1= Up to several days 2- Half of the days 3- Nearly everyday
Q10. If you had any symptoms above, how difficult has it been to do your work, take care of things at home, or get along withother people? *

Not at all difficult Somewhat difficult Very difficult Extremely Difficult

Here are some further questions about your anxiety

Choose the one response to each iteam which best describes you and your symptom for the the last 14 days
Q1. Over the last 14 days (2 wks), how often have you been bothered by feeling nervous, anxious, or on edge? *

Not at all Up to several days Half of the days Nearly everyday
Q2. Over the last 14 days (2 wks), how often have you been bothered by not being able to stop or control worry? *

Not at all Up to several days Half of the days Nearly everyday
Q3. Over the last 14 days (2 weeks), how often have you been bothered by worrying too much about different things ? *

Not at all Up to several days Half of the days Nearly everyday
Q4. Over the last 14 days (2 weeks), how often have you been bothered by trouble relaxing? *

Not at all Up to several days Half of the days Nearly everyday
Q5. Over the last 14 days (2 weeks), how often have you been bothered being so restless that it is hard to sit still ? *

Not at all Up to several days Half of the days Nearly everyday
Q6. Over the last 14 days (2 weeks), how often have you been bothered by becoming easily annoyed or irritable ? *

Not at all Up to several days Half of the days Nearly everyday
Q7. Over the last 14 days (2 weeks), how often have you been bothered by feeling afraid as if something awful might happen? *

Not at all Up to several days Half of the days Nearly everyday
Q8. If you had any symptoms above, how difficult has it been to do your work, take care of things at home, or get along with other people? *

Not at all difficult Somewhat difficult Very difficult Extremely Difficult

Review of Symptoms (ROS)
SELECT ANY & ALL symptoms you have had in the last TWO (2) WEEKS *

None, I am doing well! Fever Weight Loss Weight Gain Fatigue or Low Energy Blurred Vision Double Vision Ringing in your ears Tongue or Lip movements which you could not control Dry Mouth Drooling, excessive saliva Rapid Heart Rate Floppy feeling in Chest Chest Pain Chest Tightness Shortness of Breath Cough Constipation Diarrhea Nausae Vomiting Urinary incontinence - Loss of Bladder control Urinary retention - difficulty starting to urinate Decreased libido or Loss of Sexual desire or drive Muscle pain Joint pain Back or Neck pain Other pain Weakness Falls Tremor - shaky hands or arms Memory problems Forgetfulness Unexplained loss of Time Headaches Migraines Heat intolerance Cold intolerance Bruising Bleeding Increased Sweating Swelling of lips Rash Hives with a recent medication Anaphylaxis with a recent medication Swelling of legs, or feet Tingling in legs or arms Numbness in legs or arms
Select any of the following symptoms which you or the patient experienced since your last appointment *

None, doing well. Irritability Suicidal feelings Thoughts of death Worthless or hopeless feelings Homicidal feelings Hyperactive or Defiant Symptoms Paranoia Fearfulness Seeing things that were not actually there Hearing things that were not actually there Obsessions - Intrusive thoughts Compulsions - Compulsive actions Overspending financially Overeating or binging Restricting food intake Behaviors that have caused you social consequences Alcohol Use Legal Charges Cannabis Use since last visit Heroin Use since last visit IV drug Use since last visit Other Illegal Drug Use or experimentation
Should be Empty: