NSTMS - Followup Appointment Assessment

Follow-Up Appointment Assessment for Existing Patients

A different form is needed for TMS and Spravato Patients.

Please CLICK HERE, to be redirected to your appropriate paperwork if you are receiving TMS or Spravato.

Our patient assessments are important for tracking your physical and emotional well-being. The detail you provide is vital to developing the appropriate care plan for your individualized therapy.
Name*

First NameInitial of Last Name
PHQ-9 Calculation
This will populate automatically after you complete the form in its entirety.
Q9 of PHQ Calculation
This will populate automatically after you complete the form in its entirety.
GAD-7 Calculation
This will populate automatically after you complete the form in its entirety.
GAD-7, Q8
PHQ-9, Q10
Your Email address*
example@example.com
Which Clinician are you seeing in the office for your care today?*

Psychiatric Nurse Practitioner, Marshall Fife APRNPsychiatric Nurse Practitioner, A. Lexi Gold APRNPsychiatric Nurse Practitioner, Alexandra Harlan, APRNPsychiatric Nurse Practitioner, Kim Jones, APRNPsychiatric Nurse Practitioner, Hiliary Osborne, APRNPsychiatric Nurse Practitioner, Melissa Schneider APRNPsychiatric Nurse Practitioner, Rose Vick, APRNPsychiatrist, Jonathan Becker, DOPsychiatrist, Brent Necaise, MDPsychiatrist, Ryan Oakley, MDPsychiatrist, Eveleigh Wagner, MDPsychiatrist, Elizabeth Shultz, DOPsychiatrist, Michelle Cochran, MDTherapist Ali Self, LCSWTherapist Frances Perkins, LPC-MHSPTherapist Michael DeMarco, LPC-MHSP NCCTherapist, Angela Muterspaugh, LMFT
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 allUp to several daysHalf of the daysNearly 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 allUp to several daysHalf of the daysNearly 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 allUp to several daysHalf of the daysNearly 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 allUp to several daysHalf of the daysNearly everyday
Q5. Over the last 14 days (2 weeks), how often have you been bothered by low energy, feeling tired, or fatigued?*

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

Not at allUp to several daysHalf of the daysNearly 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 allUp to several daysHalf of the daysNearly 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 all1= Up to several days2- Half of the days3- 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 difficultSomewhat difficultVery difficultExtremely 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
G1. Over the last 14 days (2 wks), how often have you been bothered by feeling nervous, anxious, or on edge?*

Not at allUp to several daysHalf of the daysNearly everyday
G2. Over the last 14 days (2 wks), how often have you been bothered by not being able to stop or control worry?*

Not at allUp to several daysHalf of the daysNearly everyday
G3. Over the last 14 days (2 weeks), how often have you been bothered by worrying too much about different things ?*

Not at allUp to several daysHalf of the daysNearly everyday
G4. Over the last 14 days (2 weeks), how often have you been bothered by trouble relaxing?*

Not at allUp to several daysHalf of the daysNearly everyday
G5. 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 allUp to several daysHalf of the daysNearly everyday
G6. Over the last 14 days (2 weeks), how often have you been bothered by becoming easily annoyed or irritable ?*

Not at allUp to several daysHalf of the daysNearly everyday
G7. Over the last 14 days (2 weeks), how often have you been bothered by feeling afraid as if something awful might happen?*

Not at allUp to several daysHalf of the daysNearly everyday
G8. 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 difficultSomewhat difficultVery difficultExtremely Difficult

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

None, I am doing well!FeverWeight LossWeight GainFatigue or Low EnergyBlurred VisionDouble VisionRinging in your earsTongue or Lip movements which you could not controlDry MouthDrooling, excessive salivaRapid Heart RateFloppy feeling in ChestChest PainChest TightnessShortness of BreathCoughConstipationDiarrheaNausaeVomitingUrinary incontinence - Loss of Bladder controlUrinary retention - difficulty starting to urinateDecreased libido or Loss of Sexual desire or driveMuscle painJoint painBack or Neck painOther painWeaknessFallsTremor - shaky hands or armsMemory problemsForgetfulnessUnexplained loss of TimeHeadachesMigrainesHeat intoleranceCold intoleranceBruisingBleedingIncreased SweatingSwelling of lipsRashHives with a recent medicationAnaphylaxis with a recent medicationSwelling of legs, or feetTingling in legs or armsNumbness in legs or armsOther
Select any of the following symptoms which you or the patient experienced since your last appointment*

None, doing well.IrritabilitySuicidal feelingsThoughts of deathWorthless or hopeless feelingsHomicidal feelingsHyperactive or Defiant SymptomsParanoiaFearfulnessSeeing things that were not actually thereHearing things that were not actually thereObsessions - Intrusive thoughtsCompulsions - Compulsive actionsOverspending financiallyOvereating or bingingRestricting food intakeBehaviors that have caused you social consequencesAlcohol UseLegal ChargesCannabis Use since last visitHeroin Use since last visitIV drug Use since last visitOther Illegal Drug Use or experimentationOther
Should be Empty: