TMS/Esketamine Self-Screener before Consultation

Self-Screener before Consultation
Company Email
example@example.com
We would like to know if you are the Patient?*

YESNO
What relation are you to the patient?

Family memberSignificant otherConcerned friend
Record your full name*

First NameLast Name
Your Email address*
example@example.com
Phone Number to best reach you*

Area CodePhone Number
Patient's name*

First NameLast Name
Patient's Email address*
Patient's Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear

The following questions should be answered about the patient so that we can understand past and current history.
When was the first time you had problems with mood? *
What age/year was this? Approximate ages or dates are ok. *
How long has the current episode lasted (weeks, months, years)?*
Did anything work to get you well? If so, what was it? *
How many episodes of mood have you experienced? (a number and explanation) *
Who treats you currently? Is this person a doctor, psychiatrist, psychiatric nurse practitioner, or a therapist or counselor? *
Who have you seen for care in the past? Names of your past clinicians and/or therapists| counselors? *
Who is your primary care physician or clinician? *
When was the last time you saw your primary care physician or clinician? *
Have you (the patient) been hospitalized for mood problems?*

YESNO
Have you (the patient) had treatments such as ECT, TMS, or Ketamine in the past?*

YESNO