Neural Health TMS
Patient Health History
Identifying Information
Full Name
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Date of Birth
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Year
Occupation
Gender
*
Please Select
Female
Male
Marital Status
Single
Married
Divorced
Widowed
Children?
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Phone Number
*
-
Area Code
Phone Number
Okay to leave voicemail?
Yes
No
E-mail
Welcome to Our Practice
How did you hear about Neural Health Therapies?
*
What prompted you to seek consultation for TMS therapy?
*
Emergency Contact
Emergency Contact Name/Relationship
*
Phone Number
*
-
Area Code
Phone Number
Current Providers
Referring Provider Name and Phone #:
Current Psychiatrist/Prescriber Name and Phone#:
Current Therapist Name and Phone#:
Current Primary Care Doctor Name and Phone#:
Psychiatric History
Current Psychiatric Diagnoses:
History of Psychiatric Hospitalization? Please include dates.
Please describe current symptoms and duration:
History of psychotic symptoms/hallucinations?
Yes
No
History of self-injury?
Yes
No
History of suicidal ideation?
Yes
No
History of suicide attempts?
Yes
No
Trauma history?
Yes
No
Previous psychiatric medications/treatments tried (medications, therapies, previous TMS, ECT, etc. Please include any adverse reactions) ** Please include max dosages of medications and dates
Medical History
Please list current medical problems:
Current Medications (Please include all medications and supplements frequency and dosage):
Please indicate if you have had any of the following:
History Hypertension/High Blood Pressure
Low Blood Pressure
Cardiovascular Disease/MI
Heart Condition
Aneurysm
Syncope/Fainting
Kidney Disease
Urinary/Bladder Issues
Seizure Disorder
Head Injury
Head/brain tumor
GI Issues
Stroke
Glaucoma
Thryoid Issues
Cancer
Any Blood Disorders
Diabetes
Asthma/Breathing problems
Hepatitis
Liver Disease
Pregnant/Nursing
Head /brain tumor
Other
Do you have any non-removable metal object around your head (including pacemakers or any other implanted medical devices?)
Substance Abuse History:
Tobacco
Alcohol
Marijuana
Opiates
Hallucinogens
Cocaine/Stimulants
Other
How many alcoholic drinks do you consume per day?
Any other information you feel is important for us to know?
By signing below you certify that you have completed this questionnaire accurately to the best of your knowledge.
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