Transcranial Magnetic Stimulation Prescreening Packet

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Past Treatment History

MEDICATION TRIALS (Include doses, only medications used during this mood episode): Usually need two different classes and two augmentation trials.

THERAPY TRIAL (During this mood episode):

Please type or upload an up-to-date medication list and list of allergies.

Please answer each question to the best of your ability.

No problemsMinor problemModerate problemSerious problem

This instrument is designed for screening purposes only and not to be used as a diagnostic tool. Permission for use granted by RMA Hirschfeld, MD

	Not at all (0)	Several days (1)	More than half the days (2)	Nearly 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 difficult at allSomewhat difficultVery difficultExtremely difficult

	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

Not difficult at allSomewhat difficultVery difficultExtremely Difficult

Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097.

	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.

NoYes, but not in the last yearYes, in the last year

CurrentlyIn the pastNever

The following questions concern information about your potential involvement with drugs not including alcoholic beverages during the past 12 months. Carefully read each statement and decide if your answer is "Yes" or "No". Then, circle the appropriate response beside the question. In the statements "drug abuse" refers to (1) the use of prescribed or over the counter drugs in excess of the directions and (2) any non-medical use of drugs. The various classes of drugs may include: cannabis (e.g. marijuana, hash), soivents, tranquillizers (e.g. Valium), barbiturates, cocaine, stimulants (e.g. speed), hallucinogens (e.g. LSD) or narcotics (e.g. heroin Remember that the questions do not include

Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.

	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

Transcranial Magnetic Stimulation Prescreening Packet

PERTINENT MEDICAL HISTORY

Mood Disorder Questionnaire

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

Generalized Anxiety Disorder 7-item (GAD-7) scale

COLUMBIA-SUICIDE SEVERITY RATING SCALE

Alcohol Screening Questionnaire

DRUG USE QUESTIONNAIRE (DAST - 20)

Epworth Sleepiness Scale