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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 All That Apply: Head Trauma Fainting Chronic Pain Aneurysm Clips/Coils Seizures Headaches Pacemaker Stents Dizziness Migraines Aneurysm Implanted Stimulators Implanted Electrodes Ferromagnetic Implants Bullet Fragments Metal Devices/Objects Tattoos Dental Implants 6015 Harris Parkway, Suite 110, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249 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 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249 TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY Check Each Treatments You Have Had IN THE PAST (not currently taken) Dates Taken Dose Effective? List Side Effects ______ Celexa (Citalopram) ________-________ __________ ___Y ___N ________________________ ______ Lexapro (Escitalopram) ________-________ __________ ___Y ___N ________________________ ______ Luvox (Fluvoxamine) ________-________ __________ ___Y ___N ________________________ ______ Paxil (Fluoxetine) ________-________ __________ ___Y ___N ________________________ ______ Viibryd (vilazodone) ________-________ __________ ___Y ___N ________________________ ______ Geodon (Ziprasidone) ________-________ __________ ___Y ___N ________________________ ______ Invega (Paliperidone) ________-________ __________ ___Y ___N ________________________ ______ Latuda (Lurisadone) ________-________ __________ ___Y ___N ________________________ ______ Risperdal (Risperidone) ________-________ __________ ___Y ___N ________________________ ______ Saphris (Asenapine) ________-________ __________ ___Y ___N ________________________ ______ Seroquel (Quetapine) ________-________ __________ ___Y ___N ________________________ ______ Zyprexa (Olanzapine) ________-________ __________ ___Y ___N ________________________ ______ Haldol (Haloperidol) ________-________ __________ ___Y ___N ________________________ ______ Mellaril (Thioridazie) ________-________ __________ ___Y ___N ________________________ ______ Thorazine (Chlorpromazine) ________-________ __________ ___Y ___N ________________________ ______ Trilafon (Perphenazine) ________-________ __________ ___Y ___N ________________________ ______ Adderall (d/l amphetamine) ________-________ __________ ___Y ___N ________________________ ______ Dexadrine (d-amphetamine) ________-________ __________ ___Y ___N ________________________ ______ Intuniv/Tunix (Guanfacine) ________-________ __________ ___Y ___N ________________________ ______ Ritalin (Methylphenidate) ________-________ __________ ___Y ___N ________________________ ______ Strattera (Atomoxapine) ________-________ __________ ___Y ___N ________________________ ______ Catapres (Clonidine) ________-________ __________ ___Y ___N ________________________ ______ Ativan (Lorazepam) ________-________ __________ ___Y ___N ________________________ 6015 Harris Parkway, Suite 110, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249 TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY ______ Buspar (Buspirone) ________-________ __________ ___Y ___N ________________________ ______ Valium (Diazepam) ________-________ __________ ___Y ___N ________________________ ______ Klonopin (Clonazepam) ________-________ __________ ___Y ___N ________________________ ______ Estrogen Hormone ________-________ __________ ___Y ___N ________________________ ______ Progesterone Hormone ________-________ __________ ___Y ___N ________________________ ______ Testosterone Hormone ________-________ __________ ___Y ___N ________________________ ______ Thyroid Hormone ________-________ __________ ___Y ___N ________________________ ______ Minipress (Prazocin) ________-________ __________ ___Y ___N ________________________ ______ Wellbutrin (Buproprion) ________-________ __________ ___Y ___N ________________________ ______ Zoloft (Sertraline) ________-________ __________ ___Y ___N ________________________ ______ Effexor (Venlafaxine) ________-________ __________ ___Y ___N ________________________ ______ Pristiq (Desvenlafaxine) ________-________ __________ ___Y ___N ________________________ ______ Remeron (Mirtazapine) ________-________ __________ ___Y ___N ________________________ ______ Serzone (Nefazodone) ________-________ __________ ___Y ___N ________________________ ______ Desyrel (Trazodone) ________-________ __________ ___Y ___N ________________________ ______ Elavil (Amytriptyline) ________-________ __________ ___Y ___N ________________________ ______ Norpramine (Nortriptyline) ________-________ __________ ___Y ___N ________________________ ______ EMSAM (Selegiline) ________-________ __________ ___Y ___N ________________________ ______ Marploan (isocarboxazid) ________-________ __________ ___Y ___N ________________________ ______ Nardil (Phenelzine) ________-________ __________ ___Y ___N ________________________ ______ Parnate (Tranylcypromine) ________-________ __________ ___Y ___N ________________________ ______ VNS ________-________ __________ ___Y ___N ________________________ ______ Light Box ________-________ __________ ___Y ___N ________________________ ______ Lithium ________-________ __________ ___Y ___N ________________________ ______ Depakote (Valproate) ________-________ __________ ___Y ___N ________________________ 6015 Harris Parkway, Suite 110, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249 TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY ______ Keppra (Levetiracetam) ________-________ __________ ___Y ___N ________________________ ______ Lamictal (Lamotrigine) ________-________ __________ ___Y ___N ________________________ ______ Tegretol (Carbamazepine) ________-________ __________ ___Y ___N ________________________ ______ Trileptal (Oxcarbazepine) ________-________ __________ ___Y ___N ________________________ ______ Zonegran (Zonizamide) ________-________ __________ ___Y ___N ________________________ ______ Lyrica (Pregabalin) ________-________ __________ ___Y ___N ________________________ ______ Neurontin (Gabapentin) ________-________ __________ ___Y ___N ________________________ ______ Abilify (Aripiprazole) ________-________ __________ ___Y ___N ________________________ ______ Clozaril (Clozapine) ________-________ __________ ___Y ___N ________________________ ______ Fanapt (Iloperidone) ________-________ __________ ___Y ___N ________________________ 6015 Harris Parkway, Suite 110, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249 TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY TMS QUESTIONNAIRE Check All That Apply: Depressed Mood Agitation Suicidal Ideations Loss of Motivation Poor Energy Poor Self Esteem Feelings of Worthlessness Insufficient/Excessive Sleep Increased Self Esteem Inappropriate Guilt Decreased Need for Sleep Being More Talkative than Usual Racing Thoughts Weight Loss/Gain Hyperexcitability Distractibility Appetite Change Foolish Investments Indecisiveness Sexual Indiscretions Shopping/Buying Sprees Poor Concentration Suicidal Attempts Grandiosity 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 still 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 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249
