Treatment Resistant Depression Patient Questionnaire
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
Trans-Male
Trans-Female
Non-Binary
Prefer Not to Say
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Screening Questions
Have you been diagnosed with Major Depressive Disorder or Depression?
*
Yes
No
Have you ever been diagnosed with any other mental health conditions?
*
Yes
No
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
Somewhat difficult
Very difficult
Extremely difficult
Have you been involved in talk therapy to treat your depressive symptoms?
*
Yes
No
Have you tried 2+ anti-depressant medications to treat depression?
*
Yes
No
Would you be interested in learning more about transcranial magnetic stimulation (TMS), an FDA cleared, non-drug, side-effect free treatment for depression?
*
Yes
No
Contact Information
What is the best way to contact you?
*
Phone
Email
Either
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?
*
Yes
No
Submit
Should be Empty: