Tms history and questionnaire

TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY
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:_____________________________________________________________________________
Total Days Spent: ______________________________ Dates of Stay:___________________________________________________________
Name of Inpatient Treatment for Depression:_____________________________________________________________________________
Total Days Spent: ______________________________ Dates of Stay:___________________________________________________________

Name of Outpatient Treatment for Depression:___________________________________________________________________________
Total Days Spent: ______________________________ Dates of Stay:___________________________________________________________
Name of Outpatient Treatment for Depression:___________________________________________________________________________
Total Days Spent: ______________________________ Dates of Stay:___________________________________________________________

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 Al That Apply:
6015 Harris Parkway, Suite 110, Fort Worth, TX 76132 TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY
Psycotherapy/Counseling
Therapist Name:_________________________________ Frequency of Appointments: (weekly, biweekly, monthly, etc.)__________
Dates Seen:__________________ - _____________________ Outcome/Did It Help?: Yes No
Therapist Name:_________________________________ Frequency of Appointments: (weekly, biweekly, monthly, etc.)__________
Dates Seen:__________________ - _____________________ Outcome/Did It Help?: Yes No
Therapist Name:_________________________________ Frequency of Appointments: (weekly, biweekly, monthly, etc.)__________
Dates Seen:__________________ - _____________________ Outcome/Did It Help?: Yes No
Therapist Name:_________________________________ Frequency of Appointments: (weekly, biweekly, monthly, etc.)__________
Dates Seen:__________________ - _____________________ Outcome/Did It Help?: Yes No
Therapist Name:_________________________________ Frequency of Appointments: (weekly, biweekly, monthly, etc.)__________
Dates Seen:__________________ - _____________________ Outcome/Did It Help?: Yes No
CURRENT Psychiatric Medications Taken
Dates:________-________ Time Taken:__________ Medication:_______________________________________________ Dose:__________ Effectiveness:________________________________ Side-effect:_______________________________________________________________ Dates:________-________ Time Taken:__________ Medication:_______________________________________________ Dose:__________ Effectiveness:________________________________ Side-effect:_______________________________________________________________ Dates:________-________ Time Taken:__________ Medication:_______________________________________________ Dose:__________ Effectiveness:________________________________ Side-effect:_______________________________________________________________ Dates:________-________ Time Taken:__________ Medication:_______________________________________________ Dose:__________ Effectiveness:________________________________ Side-effect:_______________________________________________________________ Dates:________-________ Time Taken:__________ Medication:_______________________________________________ Dose:__________ Effectiveness:________________________________ Side-effect:_______________________________________________________________ Dates:________-________ Time Taken:__________ Medication:_______________________________________________ Dose:__________ Effectiveness:________________________________ Side-effect:_______________________________________________________________ Dates:________-________ Time Taken:__________ Medication:_______________________________________________ Dose:__________ Effectiveness:________________________________ Side-effect:_______________________________________________________________ 6015 Harris Parkway, Suite 110, Fort Worth, TX 76132 TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY
Check Each Treatments You Have Had IN THE PAST (not currently taken)

Dates Taken
Effective?
List Side Effects

______ Celexa (Citalopram)

______ Lexapro (Escitalopram)

______ Luvox (Fluvoxamine)

______ Paxil (Fluoxetine)

______ Viibryd (vilazodone)

______ Geodon (Ziprasidone)

______ Invega (Paliperidone)

______ Latuda (Lurisadone)

______ Risperdal (Risperidone)

______ Saphris (Asenapine)

______ Seroquel (Quetapine)

______ Zyprexa (Olanzapine)

______ Haldol (Haloperidol)

______ Mel aril (Thioridazie)

______ Thorazine (Chlorpromazine)

______ Trilafon (Perphenazine)

______ Adderal (d/l amphetamine)

______ Dexadrine (d-amphetamine)

______ Intuniv/Tunix (Guanfacine)

______ Ritalin (Methylphenidate)

______ Strattera (Atomoxapine)

______ Catapres (Clonidine)

______ Ativan (Lorazepam)
6015 Harris Parkway, Suite 110, Fort Worth, TX 76132 TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY
______ Buspar (Buspirone)

______ Valium (Diazepam)

______ Klonopin (Clonazepam)

______ Estrogen Hormone

______ Progesterone Hormone

______ Testosterone Hormone

______ Thyroid Hormone

______ Minipress (Prazocin)

______ Wel butrin (Buproprion)

______ Zoloft (Sertraline)

______ Effexor (Venlafaxine)

______ Pristiq (Desvenlafaxine)

______ Remeron (Mirtazapine)

______ Serzone (Nefazodone)

______ Desyrel (Trazodone)

______ Elavil (Amytriptyline)

______ Norpramine (Nortriptyline)

______ EMSAM (Selegiline)

______ Marploan (isocarboxazid)

______ Nardil (Phenelzine)

______ Parnate (Tranylcypromine)

______ VNS

______ Light Box

______ Lithium

______ Depakote (Valproate)
6015 Harris Parkway, Suite 110, Fort Worth, TX 76132 TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY
______ Keppra (Levetiracetam)

______ Lamictal (Lamotrigine)

______ Tegretol (Carbamazepine)

______ Trileptal (Oxcarbazepine)

______ Zonegran (Zonizamide)

______ Lyrica (Pregabalin)

______ Neurontin (Gabapentin)

______ Abilify (Aripiprazole)

______ Clozaril (Clozapine)

______ Fanapt (Iloperidone)
6015 Harris Parkway, Suite 110, Fort Worth, TX 76132 TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY
TMS QUESTIONNAIRE
Check Al That Apply:


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 stil 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)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
6015 Harris Parkway, Suite 110, Fort Worth, TX 76132

Source: http://www.psychiatryfortworth.com/uploads/documents/TMS-History-and-Questionnaire.pdf