NEUROPSYCHIATRY/TMS. Procedure Recommended Which procedure has your doctor recommended for your pain? Implantable Pain Pump Spinal Cord Stimulator

Transcription

1 Pre-Implant Questionnaire for Psychiatric Clearance (To help us evaluate your readiness for a surgical implant, please, fill out the following questionnaire) DATE NAME DOB Procedure Recommended Which procedure has your doctor recommended for your pain? Implantable Pain Pump Spinal Cord Stimulator Your pain and you Where is your pain located and what does it feel like? How does your pain affect your daily functioning? What is your understanding of what causes your pain? Who is helping you to cope with your pain? Who is your social support? The procedure and your pain How does this procedure help with pain? What is your understanding of that? How much improvement of your pain do you expect to get from this procedure? What do you imagine it will be like having an implanted device? Patient Signature: Date:

2 Psychiatric Intake Information (To help us best meet your psychiatric needs, please, fill out this form completely. Please, ask us if you have any questions.) NAME: BIRTHDATE: AGE: Who is your family doctor (PCP)? Do you see any other doctor(s)? Yes No (If yes, please write their name and specialty) Who is your therapist? (if applicable) Who referred you here? PCP therapist family member friend other (specify) What is the reason you are seeing (referred to) a Psychiatrist? What type of issues do you struggle with? How long have you been concerned about these issues? What else do you need help with? (please, check all that apply) Addiction Feeling tired Alcohol problem Flashbacks Anxiety Guilt Cannot concentrate Hearing voices Cannot sleep Hopelessness Depression Legal problems Eating too much Manic-depressive/Bipolar Feel like hurting others Nightmares Feel like hurting self/suicidal No motivation Feeling paranoid No appetite Obsessive Compulsive Disorder (OCD) Panic attacks Relationship problems Seeing things Sleeping too much Substance use Wish I was dead Worrying too much Other Patient Psychiatric History Have you ever seen a psychiatrist or therapist/counselor? Yes No (If yes, please list when and who you saw) Have you ever been hospitalized in a psychiatric hospital in the past? Yes No (If yes, please list when and where) Have you ever been treated for substance dependence, detox or had a problem with alcohol or drugs? Yes No (If yes, please list when and where) Patient Signature Date pg 1 of 7

3 Personal History Have you had any recent stressors/changes in your life over the past year? (please, check all that apply) Abuse loss of loved one separation/divorce academic problems pregnancy had a miscarriage/ abortion legal problems changed job medical problems relationship problems relocation Other 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: Have you experienced any of the following symptoms in the past week? Y N Y N Y N Y N Blackouts / Dizziness Chills or Fever Dental Problems Feeling Very Sleepy Frequent Coughing Frequent Diarrhea Headaches Hearing loss Muscle weakness Nausea Nervousness Nosebleeds Skin Sores Spitting Up Blood Stiff joints Stomach Aches Trouble Breathing Visual problems Other What Medications are you CURRENTLY taking? (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 Patient Signature Date pg 2 of 7

4 PAST Psychiatric Medication Trials Please, list below all medications that you have taken in the PAST for PSYCHIATRIC/mental health/behavioral conditions. (for each medication, please, include the what was the highest dose you took, the longest time you took it for (days, weeks, months, years), if it helped (helped, stopped working, no help) and reason for stopping it). 1. Medication Name Highest Dose (mg) Longest time (days, wks, mos, yrs) Was it Helpful/Why was it stopped Check here and use back of page, if more space is needed **** Please, continue with Social History Questionnaire on next page **** Patient Signature Date pg 3 of 7

5 Developmental, Social, and Family History (Please, help us understand you better by filling out the following 4 pages questionnaire) Childhood How old are you now? Were you adopted? Do you have any brothers or sisters? (if yes, please list their names and their age; if anyone deceased, when?) Were you raised by both parents? (if no, please describe reason, eg: divorce, death, and at what age that happened) How old are your parents? Father Mother (if deceased, when did it happened?) Please, describe your FATHER and your relationship with him. Please, describe your MOTHER and your relationship with her. Did you experience any type of abuse growing up? (if yes, please indicate if emotional [E], physical [P], or sexual [S], at what ages and by whom?) Did anything else happen in your childhood that you feel it is still affecting you today? (if yes, please describe) Education Did you have to attend any special education classes? (if yes, describe why) Did you have to repeat any grades in school? (if yes, what grades and why, eg: academic or behavioral problems?) Did you have any disciplinary problems in school? (if yes, please describe) Did you have to move to different schools growing up? (if yes, at what ages and why) How far did you go in school? Did not finish high school HS/GED Trade school Some college Bachelor Master Doctorate What was your major/trade? If you did not complete HS or college, please describe the reason. Patient Signature Date pg 4 of 7

6 Marital Status/Family Please, check the box that best describes you Single/Never Married Married Separated Divorced Widowed (If more than 1 marriage, how long did each last and why did it end) If married, what is your spouse s occupation and how would you describe your marriage? How long have you lived in your current home? Besides you, who else lives at home? Do you have any children? (if yes, please, list their names and ages) Do you have any grandchildren? (if yes, how old are they?) Occupation Do you currently work? (If no, please check reason below and how long you have not been working) Homemaker Disabled Retired Other For how long? If you currently work, how long have you been in your present job? What is your occupation? What other jobs did you have in the past? What is the longest you have been in a certain job (and what type of job was that)? Financial Stressors Do you have any significant amount of debt? Do you feel that your financial problems are unmanageable, affecting you mental health? If you are not employed, how do you support yourself/your family? Legal Stressors Are you currently involved in any legal proceedings (including divorce, custody)? Have you ever been arrested or been in jail? (if yes, please describe) Are you currently on probation or parole? (if yes, please describe why and when it will be over) Patient Signature Date pg 5 of 7

7 Military History Have you ever served in the military? (if yes, please, list when, what branch, highest rank, type of discharge, and any service-connected disability) Religion/Spirituality What best describes your religion affiliation? Baptist Catholic Mormon Presbyterian Protestant Non Denominational Other How often do you attend services/practice your faith? How important is religion/spirituality to you?(please, rate from 1-5) Not important Very important Hobbies/Interests How do you spend your free time? What are some activities that you normally enjoy? What type of exercise/physical activity do you do (if any) and how often? Family Psychiatric History Please, list any blood-relatives (parents, siblings, grandparents, aunts, uncles, cousins, etc.) with any of the psychiatric conditions below Diagnoses Relationship to you (please also indicate which side: mother s [M] or father s [F] side) Depression Anxiety/Panic Attacks Bipolar Schizophrenia OCD Suicide attempt Alcohol/Drug Abuse Eating disorder ADHD Family Medical History Please, list any blood-relatives (parents, siblings, grandparents, aunts, uncles, cousins, etc.) with any of the following medical conditions. Diagnoses Relationship to you Alzheimer s Dementia Diabetes Heart attacks Heart problems Patient Signature Date pg 6 of 7

8 Hypertension Seizures Stroke Thyroid problems Other NEUROPSYCHIATRY/TMS Substance Use History Tobacco Do you smoke cigarettes or chew tobacco? (if yes, how much/often?) (If no, have you ever smoked cigarettes? Yes, quit ago No) Caffeine Do you drink any caffeinated beverages, (eg: coffee, tea, sodas, energy drinks) or use pills with caffeine? (if yes, please describe what form and how much) Alcohol Please, indicate what best describes your alcohol consumption? Never had a drink Currently drinking ( drinks/day, drinks/week, drinks/month, drinks/year) Quit ago If drinking, at what age did you have your first drink? Do you feel that your drinking ever became a problem? (if yes, at what age and how much were you drinking at its highest) Have you ever experienced any of the following as a result of your drinking? (check all that apply) Hand tremors Blackouts Seizures DTs DUI Relationship Problems Legal Problems Substances Have you ever used (in the past) and/or are you currently using (present) any of the substances on the following table? If you are currently using any of these substances, please describe the amount, frequency, time of last use (eg: 2 days ago), and if you ever felt that you had a problem with that substance 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 ****** Thank you for filling out this Questionnaire.****** Patient Signature Date pg 7 of 7

9 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 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 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

10 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

11 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 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 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 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