Acuity TMS Prescreening Intake Form

Acuity Transcranial Magnetic Stimulation (TMS) Prescreening Intake Form
Full Name
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is your Psychiatrist?
Who is your Therapist?
Your Depression and how it affects you:
Anhedonia (cannot enjoy things)yes/no
Changes in appetite (weight gain/loss)yes/no
Cognitive Impairmentyes/no
Fatigue (low energy)yes/no
Guilty Feelingsyes/no
Helpless Feelingsyes/no
Hopeless Feelingsyes/no
Indecisiveness yes/no
Interpersonal Withdrawalyes/no
Irritabiltiy yes/no
Loss of Interest yes/no
Loss of Motivationyes/no
Pessimism yes/no
Relationships affectedyes/no
Sadnessyes/no
Trouble Sleepingyes/no
Suicidal Ideationyes/no
Suicidal Planningyes/no
Work Performance Affected yes/no
Worthless Feelingsyes/no
The TMS Therapy Procedure and your Depression:
Why are you considering TMS Therapy Now?
Anti Depressant Medications (Present):
Name / mg / Start Date-End Date
Anti Depressant Medications (Present):
Name / mg / Start Date-End Date
Anti Depressant Medications (Past):
Name / mg / Start Date-End Date
Anti Depressant Medications (Past):
Name / mg / Start Date-End Date
Anti Depressant Medications (Past):
Name / mg / Start Date-End Date
Are you currently taking or have you ever taken any medication for a seizure disorder? If so, what medication
Start Date

MonthDayYear
Date
Stop Date

MonthDayYear
Date
Insurance Provider Information:
Insurance Provider
Group Number
ID Number
Phone Number
Please enter a valid phone number.
Assessment Taken By
Assessment Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Social Secuity #
Should be Empty: