NEW PATIENT CONTACT & ELIGIBILTY FOR TMS

Pearl Health Clinic thanks you for your interest in TMS therapy for the treatment of Major Depressive Disorder. For our providers to ensure your eligibility for this treatment, please complete this questionnaire FULLY. We need your past mental health records indicating diagnosis and medications tried.

It may be necessary to contact your previous providers or pharmacy to gather this necessary information. Please submit this completed packet electronically, or drop off at the clinic. We will contact you as soon as possible after your eligibility has been determined.

If you need assistance, please contact our office and speak to Cissy Edwards our TMS Treator 208-346-7500 EXT 210. Thank you.

First Name *

Last Name *

Date of birth: * +

Street Address *

City *

Zip Code *

Phone Number *

Email Address *

Insurance Company *

Policy # *

How did you hear about Pearl Health/TMS?

History of the Disease

What is the presenting problem (why are you requesting TMS?) *

Current symptoms: *

Age of onset: *

How does your depression negatively impact your life? (i.e. work, school, parenting, social, activities of daily living, financially) *

History of suicidal thoughts or attempts (details):

History of the Disease

Previous Psychotherapy (Counselor/psychologist)

What type of therapy? (please check all that apply) *

How long they were seen by this provider?

Did the patient see this provider for 6 consecutive weeks? *

Yes

No

Was the therapy beneficial? *

Yes

No

Outcome:

Current Therapist (Counselor/psychologist)

What type of therapy? (please check all that apply) *

How long they were seen by this provider?

Did the patient see this provider for 6 consecutive weeks? *

Yes

No

Was the therapy beneficial? *

Yes

No

Outcome:

INPATIENT TREATMENT

Facility Name

Date of admission

Date of discharge

Reason for admission

Current primary care physician:

Are the above providers aware of the proposed TMS treatments? *

Yes

No

Date of most recent medical exam by the primary care provider:

MEDICATIONS / ANTIDEPRESSANTS

Current Medications

	Name	Dose	How do you take this medication
1	Name	Dose	How do you take this medication
2	Name	Dose	How do you take this medication
3	Name	Dose	How do you take this medication
4	Name	Dose	How do you take this medication
5	Name	Dose	How do you take this medication
6	Name	Dose	How do you take this medication

Medications for depression taken in the past:

	Name	Dosage	Dates Tried	Duration	Outcome, side effects, therapeutic dose?
1	Name	Dosage	Dates Tried	Duration	Outcome, side effects, therapeutic dose?
2	Name	Dosage	Dates Tried	Duration	Outcome, side effects, therapeutic dose?
3	Name	Dosage	Dates Tried	Duration	Outcome, side effects, therapeutic dose?
4	Name	Dosage	Dates Tried	Duration	Outcome, side effects, therapeutic dose?

History of TMS *

Yes

No

Date of previous treatment

Response to TMS Treatment:

ECT (Electroconvulsive therapy) *

Yes

No

Date

Location

Outcome

Does the patient have any of the following contraindications

Yes

No

Ever had metal in or around head: *

Yes

No

Dementia, stroke, or Parkinson's *

Yes

No

Seizure disorder or history of seizures *

Yes

No

Vegas nerve stimulator or other implanted stimulators *

Yes

No

Magnetic, metals implanted in head or neck within 11.8 inches of TMS coil placement *

Yes

No

Acute or psychotic disorder *

Yes

No

Substance abuse at the time of treatment *

Yes

No

Do you have any serious illnesses? *

Yes

No

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? *

	Several Days	More than half the days	Nearly every day
	1	2	3
Little interest or pleasure in doing things	1	2	3
Feeling down, depressed, or hopeless	1	2	3
Trouble falling or staying asleep, or sleeping too much	1	2	3
Feeling tired or having little energy	1	2	3
Poor appetite or overeating	1	2	3
Feeling bad about yourself – or that you are a failure or have let yourself or your family down	1	2	3
Trouble concentrating on things, such as reading the newspaper or watching television	1	2	3
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.	1	2	3
Thoughts that you would be better off dead or of hurting yourself in some way.	1	2	3

FOR OFFICE CODING: 0 + + +

TOTAL:

Please circle one. *

	Not difficult at all	Somewhat difficult	Very difficult	Extremely 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.	Not difficult at all	Somewhat difficult	Very difficult	Extremely difficult