NEUROPSYCHIATRY/TMS NAME: BIRTHDATE: AGE: Who is your Psychiatrist? Who is your Therapist?

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1 Transcranial Magnetic Stimulation (TMS) Consultation Intake (To see if you are a candidate for TMS Therapy, please fill out the following questionnaire) NAME: BIRTHDATE: AGE: Who is your Psychiatrist? Who is your Therapist? Who referred you to us or how did you hear about us? Your Depression and how it affects you Please check all depression symptoms below that may apply to you: Anhedonia (cannot enjoy things), Changes in appetite (weight gain/loss), Cognitive impairment, Fatigue (low energy), Guilty feelings, Helpless feelings, Hopeless feelings, Indecisiveness, Interpersonal withdrawal, Irritability, Loss of interest, Loss of motivation, Pessimism, Relationships affected, Sadness, Suicidal ideation, Suicide planning, Trouble sleeping, Work Performance Affected, Worthless feelings, Other The TMS Therapy procedure and your depression How is your depression affecting your life, your relationships, your finances and your job? Why are you considering TMS Therapy now? What is your understanding of TMS Therapy? Patient Signature: Date: pg. 1

2 How much improvement do you expect to get from TMS Therapy? What do you imagine it will be like after TMS Therapy? Do you have any reservations/concerns about TMS Therapy? Patient Psychiatric History Please, list the psychiatric diagnoses that you have been given. Diagnosis given By Who When Have you ever attempted suicide? Yes No (If yes, please describe, including how many times and dates) Have you ever had electroconvulsive therapy (ECT)? Yes No (If yes, list # sessions and dates) Please, list any psychiatric hospitalizations you might have had in the past. Hospital Name City, State Dates Patient Signature: Date: pg. 2

3 Please, list any psychiatric medications your may have taken IN THE PAST for your depression. Past Medication Trials/ Highest Dose Reason for stopping No Help (NH)/ Some Help (SH)/ Stopped Working (SW)/ Side Effects (SE) Dates/ Longest time taken Patient Medical History What Medical Problems do you have? (please, check all that apply) Allergies, Anemia, Asthma, Cancer, Crohn s/ulcerative Colitis, Chronic Pain, Diabetes, Fibromyalgia, Heart attacks, Hepatitis, High Cholesterol, Hypertension, Irritable Bowel Syndrome (IBS) Kidney problems, Liver problems, Low Testosterone, Neuropathy, Reflux, Seizures, Sleep apnea, Stomach ulcers, Strokes, Low Thyroid, Urinary Tract Infections, Other: What Surgeries have you had? (please, check all that apply) Appendectomy Back surgery Colon removal Cosmetic surgery For Cancer Gallbladder removal Heart Bypass Hysterectomy Neck surgery Skin graft Thyroid removal Tonsillectomy Tube ligation Other: Are you Allergic to any medications? Yes No (if yes, please list which ones) Penicillin Sulfa Codeine Iodine ASA Other: Patient Signature: Date: pg. 3

4 Medications NEUROPSYCHIATRY/TMS What Medications are you CURRENTLY taking? List psychiatric meds first. Include OTC meds, supplements Medication Name Dose (mg) How many times a day? Please, use back of paper if you need more space and check here Over Family Psychiatric History Please, list any blood-relatives (parents, siblings, grandparents, aunts, uncles, cousins, etc.) with any of the psychiatric conditions below Diagnoses Depression Anxiety/Panic Attacks Bipolar Schizophrenia OCD Suicide attempt Alcohol/Drug Abuse Eating disorder ADHD Relationship to you (please also indicate which side: mother s [M] or father s [F] side) Substance Use History TOBACCO Do you smoke cigarettes or chew tobacco? Yes No (If yes, please describe) How much for how many years If you used to smoke, when did you quit? CAFFEINE Patient Signature: Date: pg. 4

5 Do you drink any caffeinated beverages, (eg: coffee, tea, sodas, energy drinks) or use pills with caffeine? Yes No (If yes, please describe what type and how much) ALCOHOL Do you drink any alcohol? Yes No (If yes, please describe what type and how much) Has alcohol ever become a problem? Yes No (If yes, please describe when and what happened) SUBSTANCES Do you have a presently use or have a history of substance abuse? Yes No (If yes, please check all that apply and explain below) Substance Past Present How much How often Last use Problem? Amphetamines(speed) Cocaine(crack) Ecstasy(XTC) Heroin LSD Marijuana(weed) Pain pills PCP i.v. drugs Other Please, fill out Safety Screen on next page Patient Signature: Date: pg. 5

6 TMS Patient Safety Screen NAME: BIRTHDATE: AGE: Please, check if you had any of the following: Yes No Yes No Aneurysm clips or coils Blood vessel coil Bone growth stimulator Cardiac pacemaker or wires Cardiac stents, filters, or metallic valves Carotid or cerebral stents Cervical fixation devices Cochlear implant/ear implant CSF (cerebrospinal fluid) shunt Deep brain stimulator Dental implants Eye implants Hearing aid Implanted insulin pump Internal cardioverter defibrillator (lcd) Medication patch/nicotine patch Comments: Metallic devices implanted in your head Other implanted metal or device Portable glucose monitor Programmable shunt or valve Radioactive seeds Shrapnel, bullets, pellets, BBs, or other metal fragments Surgical clips, staples, or sutures Tattoo Tracheotomy Vagus nerve stimulator (VNS) VeriChip microtransponder Wearable cardioverter defibrillator Wearable infusion pump Wearable monitor (e.g., heart monitor) Other (please specify): Height Weight (lbs) WOMEN ONLY Are you pregnant? Yes No Last menstrual period: Have you ever been a machinist, welder, or metal worker? Yes No Have you ever had a facial injury from metal and/or metal removed from your eyes? Yes No Have you ever had complications from an MRI? Yes No Patient Signature Physician Signature Date Date Patient Signature: Date: pg. 6

7 PATIENT HEALTH QUESTIONNAIRE (PHQ9) Name: Date: Over the last 2 weeks, how often have you been bothered by any of the following problems (please, circle your answer) Not at all Several days More than half the days Nearly every day 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying 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 your 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 add columns + + TOTAL 10. If you 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 other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult

8 STABLE RESOURCE TOOLKIT Mood Disorder Questionnaire Patient Name Date of Visit Please answer each question to the best of your ability 1. Has there ever been a period of time when you were not your usual self and... YES NO... you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?...you were so irritable that you shouted at people or started fights or arguments?...you felt much more self-confident than usual?...you got much less sleep than usual and found that you didn t really miss it?...you were more talkative or spoke much faster than usual?...thoughts raced through your head or you couldn t slow your mind down?... you were so easily distracted by things around you that you had trouble concentrating or staying on track?...you had more energy than usual?...you were much more active or did many more things than usual?... you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?...you were much more interested in sex than usual?... you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?...spending money got you or your family in trouble? 2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? 3. How much of a problem did any of these cause you - like being unable to work; having family, money or legal troubles; getting into arguments or fights? No problems Minor problem Moderate problem Serious 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

9 BURN S ANXIETY INVENTORY Instructions: Circle the answer that best describes how much that symptom or problem has bothered you during the past seven (7) days. Rating Scale: 0 - Not at all, 1 - Somewhat, 2 - Moderately, 3 - A lot Category I: Anxious Feelings 1. Anxiety, nervousness, worry or fear Not at all Somewhat Moderately A lot 2. Feeling that things around you are strange, unreal or foggy Not at all Somewhat Moderately A lot 3. Feeling detached from all or part of your body Not at all Somewhat Moderately A lot 4. Sudden, unexpected panic spells Not at all Somewhat Moderately A lot 5. Apprehension or a sense of impending doom Not at all Somewhat Moderately A lot 6. Feeling tense, stressed, "uptight" or on edge Not at all Somewhat Moderately A lot Category II: Anxious Thoughts 7. Difficulty Concentrating Not at all Somewhat Moderately A lot 8. Racing thoughts or having your mind jump from one thing to next Not at all Somewhat Moderately A lot 9. Frightening fantasies or daydreams Not at all Somewhat Moderately A lot 10. Feeling that you're on the verge of losing control Not at all Somewhat Moderately A lot 11. Fears of cracking up or going crazy Not at all Somewhat Moderately A lot 12. Fears of fainting or passing out Not at all Somewhat Moderately A lot 13. Fears of physical illness or heart attacks or dying Not at all Somewhat Moderately A lot 14. Concerns about looking foolish or inadequate in front of others Not at all Somewhat Moderately A lot 15. Fears of being alone, isolated or abandoned Not at all Somewhat Moderately A lot 16. Fears of criticism or disapproval Not at all Somewhat Moderately A lot 17. Fears that something terrible is about to happen Not at all Somewhat Moderately A lot Category III: Physical Symptoms 18. Skipping or racing or pounding of the heart Not at all Somewhat Moderately A lot 19. Pain, pressure or tightness in the chest Not at all Somewhat Moderately A lot 20. Tingling or numbness in the toes or fingers Not at all Somewhat Moderately A lot 21. Butterflies or discomfort in the stomach Not at all Somewhat Moderately A lot 22. Constipation or diarrhea Not at all Somewhat Moderately A lot 23. Restlessness or jumpiness Not at all Somewhat Moderately A lot 24. Tight, tense muscles Not at all Somewhat Moderately A lot 25. Sweating not brought on by heat Not at all Somewhat Moderately A lot 26. A lump in the throat Not at all Somewhat Moderately A lot 27. Trembling or shaking Not at all Somewhat Moderately A lot 28. Rubbery or "jelly" legs Not at all Somewhat Moderately A lot 29. Feeling dizzy, light-headed or off balance Not at all Somewhat Moderately A lot 30. Choking or smothering sensations or difficulty breathing Not at all Somewhat Moderately A lot 31. Headaches or pains in the neck or back Not at all Somewhat Moderately A lot 32. Hot flashes or cold chills Not at all Somewhat Moderately A lot 33. Feeling tired, weak or easily exhausted Not at all Somewhat Moderately A lot Name Date Total 0-4 Minimal or No Anxiety; 5-10 Borderline; Mild; Moderate; Severe; Extreme Anxiety or Panic