Transcranial Magnetic Stimulation Prescreening Packet

Transcranial Magnetic Stimulation Prescreening Packet
NAME
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
INSURANCE COMPANY NAME
MEMBER ID#
Past Treatment History

MEDICATION TRIALS (Include doses, only medications used during this mood episode): Usually need two different classes and two augmentation trials.
1.
Dates of use:
Reason Stopped
2.
Dates of use:
Reason Stopped
3.
Dates of use:
Reason Stopped
4.
Dates of use:
Reason Stopped
THERAPY TRIAL (During this mood episode):
Therapist
Dates
OTHER PREVIOUS TREATMENT (ECT, TMS, Ketamine, etc:

	Not at all (0)	Several days (1)	More than half the days (2)	Nerly every day (3)
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself–or that you are a failure or have let yourself or family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

	Not at all sure (0)	Several Days (1)	Over half the days (2)	Nearly every day (3)
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

	YES	NO
Have you wished you were dead or wished you could go to sleep and not wake up?
Have you actually had any thoughts of killing yourself?
Have you been thinking about how you might kill yourself?
Have you had these thoughts and had some intention of acting on them?
Have you started to work out or worked out the details of how to kill yourself and do you intend to carry out this plan?
Have you done anything, started to do anything, or prepared to do anything to end your life? Examples: collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn't jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.

	YES	NO
1. Have you used drugs other than those required for medical purposes?
2. Have you abused prescription drugs?
3. Do you abuse more than one drug at a time?
4. Can you get through the week without using drugs?
5. Are you always able to stop using drugs when you want to?
6. Have you had "blackouts" or "flashbacks" as a result of drug use?
7. Do you ever feel bad or guilty about your drug use?
8. Does your spouse (or parents) ever complain about your involvement with drugs?
9. Has drug abuse created problems between you and your spouse or your parents?
10. Have you lost friends because of your use of drugs?
11. Have you neglected your family because of your use of drugs?
12. Have you been in trouble at work (or school) because of drug abuse?
13. Have you lost your job because of drug abuse?
14. Have you gotten into fights when under the influence of drugs?
15. Have you engaged in illegal activities in order to obtain drugs?
16. Have you been arrested for possession of illegal drugs?
17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
18. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?
19. Have you gone to anyone for help for drug problem?
20. Have you been involved in a treatment program specifically related to drug use?

	Would never nod off - 0	Slight chance of nodding off - 1	Moderate chance of nodding off - 2	High chance of nodding off - 3
Sitting and reading
Sitting, inactive, in a public place (e.g. in a meeting, theater, or dinner event)
As a passenger in a car for an hour or more without stopping for a break
Lying down to rest when circumstances permit
Sitting and talking to someone
Sitting quietly after a meal without alcohol
In a car, while stopped for a few minutes in traffic or at a light
Watching TV

Mood Disorder Questionnaire