NEW PATIENT CONTACT & ELIGIBILTY FOR TMS

Pearl Health Clinic thanks you for your interest in TMS – Treatment for depressive symptoms.  In order for our providers to determine whether you would be a good candidate for TMS Treatments, the following information needs to be completed FULLY.  We will also need your previous records (indicating past mental health medications and most recent diagnosis) and attached to this questionnaire.

It may be necessary to contact previous providers and pharmacies to gather this information. Once all the information is gathered, please drop off this packet to Pearl Health Clinic.  Our providers will then review the questionnaire and records. Our office will notify you of the decision. If you need any assistance with filling out this form.

Please contact Jenn Knutson, LPN at Pearl Health Clinic.

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History of the Disease

Are the above providers aware of the proposed TMS treatments? *
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MEDICATIONS / ANTIDEPRESSANTS

Current Medications

 NameDoseHow do you take this medication
1
2
3
4
5
6
Medications for depression taken in the past:
 NameDosageDates TriedDurationOutcome, side effects, therapeutic dose?
1
2
3
4
History of TMS *
ECT (Electroconvulsive therapy) *

Does the patient have any of the following contraindications

Ever had metal in or around head: *
Dementia, stroke, or Parkinson's *
Seizure disorder or history of seizures *
Dementia, stroke, or Parkinson's *
Vegas nerve stimulator or other implanted stimulators *
Magnetic, metals implanted in head or neck within 11.8 inches of TMS coil placement *
Acute or psychotic disorder *
Substance abuse at the time of treatment *
Do you have any serious illnesses? *
Non adherence of previous treatment for depression *

If you have answered yes or are unsure, please gather medical records and fax or drop off at the office as soon as possible.

PHQ 9 Depression Screening

Over the Last 2 Weeks, how often have you been bothered by any of the following problems? *
Not at AllSeveral DaysMore than half the daysNearly every day
0123
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
Trouble concentrating on things, such as reading the newspaper or watching television
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 that usual.
Thoughts that you would be better off dead or of hurting yourself in some way.
FOR OFFICE CODING:      0                        +                  +                   
 
TOTAL:                                  
Please circle one. *
 Not difficult at allSomewhat difficultVery difficultExtremely difficult
If you have 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?  Please circle one.
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