Mental Health Snapshot

Note: The information provided is for educational purposes only. The information is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Consult with a qualified and licensed physician or other qualified health care provider with any questions regarding a medical condition.

YOUR MEDICAL HISTORY

In the past 2 weeks, how often have you been bothered by any of the following problems:

1. Little interest or pleasure in doing things *

Not at all

Several days

More than half the days

Nearly every day

2. Feeling down, depressed or hopeless. *

Not at all

Several days

More than half the days

Nearly every day

3. Trouble falling asleep, staying asleep, or sleeping too much. *

Not at all

Several days

More than half the days

Nearly every day

4. Feeling tired or having little energy. *

Not at all

Several days

More than half the days

Nearly every day

5. Poor appetite or overeating. *

Not at all

Several days

More than half the days

Nearly every day

6. Feeling bad about yourself - or feeling that you are a failure or that you have let yourself or your family down. *

Not at all

Several days

More than half the days

Nearly every day

7. Trouble concentrating on things, such as reading the newspaper or watching television. *

Not at all

Several days

More than half the days

Nearly every day

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 at lot more than usual. *

Not at all

Several days

More than half the days

Nearly every day

9. Thoughts that you would be better off dead or of hurting yourself in some way. *

Not at all

Several days

More than half the days

Nearly every day

10. Have you been through counseling or psychotherapy? *

Yes

11. Have you tried TMS Therapy in the past? *

Yes

12. How many antidepressant medications have you tried? *

None

3 or more

13. Do you have a metal implanted in or around the head (aneurysm coil or clip, metal plate, ocular implant, stent or any other metal)? *

Yes

14. Do you have a seizure disorder/epilepsy? *

Yes

15. Have you ever been diagnosed or treated for bipolar disorder, schizoaffective disorder or schizophrenia? *

Yes

16. If in recovery from substance use disorder, are you at least 90 days clean and sober? *

Yes - I am in recovery

No - Still suffering from substance use disorder

Not applicable - I do not have substance use disorder

17. Do you have any of the following: cerebrovascular disease, dementia, history of repetitive or severe head trauma, increased intracranial pressure, or primary or secondary tumors in the central nervous system? *

Yes

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Once you submit this form, a member from our TMS Therapy team will assess your results and contact you to discuss.