TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY
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1 TMS - DEPRESSION HISTORY Date: Patient Name: DOB: How did you hear about TMS? What do you know about TMS? Referring Physician? Name of Practice: Name of Inpatient Treatment for Depression: Name of Inpatient Treatment for Depression: Name of Outpatient Treatment for Depression: Name of Outpatient Treatment for Depression: Name of Facility for ECT Treatment: Total Sessions: Dates of Treatment: Response to ECT Treatment: None Partial Remission Name of Facility for TMS Treatment: Total Sessions: Dates of Treatment: Response to TMS Treatment: None Partial Remission Other Treatments for Depression: (date, type of treatment, effectiveness) Check All That Apply: Head Trauma Fainting Chronic Pain Aneurysm Clips/Coils Seizures Headaches Pacemaker Stents Dizziness Migraines Aneurysm Implanted Stimulators Implanted Electrodes Ferromagnetic Implants Bullet Fragments Metal Devices/Objects Tattoos Dental Implants
2 Psycotherapy/Counseling CURRENT Psychiatric Medications Taken
3 Check Each Treatments You Have Had IN THE PAST (not currently taken) Dates Taken Dose Effective? List Side Effects Celexa (Citalopram) - Y N Lexapro (Escitalopram) - Y N Luvox (Fluvoxamine) - Y N Paxil (Fluoxetine) - Y N Viibryd (vilazodone) - Y N Geodon (Ziprasidone) - Y N Invega (Paliperidone) - Y N Latuda (Lurisadone) - Y N Risperdal (Risperidone) - Y N Saphris (Asenapine) - Y N Seroquel (Quetapine) - Y N Zyprexa (Olanzapine) - Y N Haldol (Haloperidol) - Y N Mellaril (Thioridazie) - Y N Thorazine (Chlorpromazine) - Y N Trilafon (Perphenazine) - Y N Adderall (d/l amphetamine) - Y N Dexadrine (d-amphetamine) - Y N Intuniv/Tunix (Guanfacine) - Y N Ritalin (Methylphenidate) - Y N Strattera (Atomoxapine) - Y N Catapres (Clonidine) - Y N Ativan (Lorazepam) - Y N
4 Buspar (Buspirone) - Y N Valium (Diazepam) - Y N Klonopin (Clonazepam) - Y N Estrogen Hormone - Y N Progesterone Hormone - Y N Testosterone Hormone - Y N Thyroid Hormone - Y N Minipress (Prazocin) - Y N Wellbutrin (Buproprion) - Y N Zoloft (Sertraline) - Y N Effexor (Venlafaxine) - Y N Pristiq (Desvenlafaxine) - Y N Remeron (Mirtazapine) - Y N Serzone (Nefazodone) - Y N Desyrel (Trazodone) - Y N Elavil (Amytriptyline) - Y N Norpramine (Nortriptyline) - Y N EMSAM (Selegiline) - Y N Marploan (isocarboxazid) - Y N Nardil (Phenelzine) - Y N Parnate (Tranylcypromine) - Y N VNS - Y N Light Box - Y N Lithium - Y N Depakote (Valproate) - Y N
5 Keppra (Levetiracetam) - Y N Lamictal (Lamotrigine) - Y N Tegretol (Carbamazepine) - Y N Trileptal (Oxcarbazepine) - Y N Zonegran (Zonizamide) - Y N Lyrica (Pregabalin) - Y N Neurontin (Gabapentin) - Y N Abilify (Aripiprazole) - Y N Clozaril (Clozapine) - Y N Fanapt (Iloperidone) - Y N
6 Check All That Apply: TMS QUESTIONNAIRE Depressed Mood Agitation Suicidal Ideations Loss of Motivation Poor Energy Poor Self Esteem Feelings of Worthlessness Insufficient/Excessive Sleep Increased Self Esteem Inappropriate Guilt Decreased Need for Sleep Being More Talkative than Usual Racing Thoughts Weight Loss/Gain Hyperexcitability Distractibility Appetite Change Foolish Investments Indecisiveness Sexual Indiscretions Shopping/Buying Sprees Poor Concentration Suicidal Attempts Grandiosity Has your motivation and desire to accomplish more changed? How? Has depression caused you to miss work or to be entirely unable to work? How? When? Which Job or Career? Has depression caused you to perform at less than your best? How? When? Do you still enjoy performing the same activities that you use to be involved in the past? (Name Activities) Do you feel your relationships with your family and friends have been affected due to your depression? How? Do you have days that you neglect your basic personal needs? Explain. (hygiene, skipping meals, unhealthy eating habits)
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