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

Area Code Phone Number
Patient's name*

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

Area Code Phone Number
Date of Birth*

Month Day Year

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