NSTMS - TMS Depression Screener & Assessments

Depression Screener & Assessments for Consultation
Are you the Patient? *

YES NO
What relation are you to the patient?

Family member Significant other Concerned friend
Record your full name *

First Name Last Name
Your Email address *
example@example.com
A Phone Number to reach you *

Area Code Phone Number
Patient's name *

First Name Last Name

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? Approximates 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 | clinician? *
When was the last time you saw your primary care physician | clinician? *
Have you (the patient) been hospitalized for mood problems? *

YES NO
Have you (the patient) had treatments such as ECT, TMS, or Ketamine in the past? *

YES NO