Treatment Resistant Depression Patient Questionnaire
Date of Birth
Prefer Not to Say
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Have you been diagnosed with Major Depressive Disorder or Depression?
Have you ever been diagnosed with any other mental health conditions?
If yes, which mental health condition have you been diagnosed with?
Over the last two weeks, how often have you been bothered by any of the following:
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could notice. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead, or of hurting yourself
If you have checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with others?
Not difficult at all
Have you been involved in talk therapy to treat your depressive symptoms?
Have you tried 2+ anti-depressant medications to treat depression?
Would you be interested in learning more about transcranial magnetic stimulation (TMS), an FDA cleared, non-drug, side-effect free treatment for depression?
What is the best way to contact you?
What is the best time to contact you?
Would you like our center specialist to send you emails with information about our treatments at Uptown Psych?
Should be Empty: