TMS Clinical Questionnaire
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Psychiatric History
Please List All Psychiatric Diagnoses:
Please select any of the following psych medications you have taken:
Helpful
Not Helpful
Currently Taking?
Adverse Reaction?
Comments
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Fluvoxamine (Luvox)
Citalopram (Celexa)
Escitalopram (Lexapro)
Desipramine (Norpramin)
Imipramine (Tofranil)
Doxepin (Sinequan)
Clomipramine (Anafranil)
Nortriptyline (Pamelor)
Bupropion (Wellbutrin)
Venlafaxine (Effexor)
Duloxetine (Cymbalta)
Desvenlafaxine (Pristiq)
Vortioxetine (Trintellix)
Vilazodone (Viibryd)
Paliperidone (Invega)
Chlorpromazine (Thorazine)
Haloperidol (Haldol)
Loxapine (Loxitane)
Fluphenazine (Proloxin)
Clozapine (Clozaril)
Olanzapine (Zyprexa)
Quatran (Seroquel)
Risperidone (Risperdal)
Cariprazine (Vraylar)
Brexpiprazole (Rexulti)
Aripiprazole (Abilify)
Alprazolam (Xanax)
Diazepam (Valium)
Buspirone (BuSpar)
Lorazepam (Ativan)
Clonazepam (Klonopin)
Hydroxyzine (Vistaril, Atarax)
Buprenorphine (Suboxone)
Varenicline (Chantix)
Methadone (Dolophine)
Carbamazepine (Tegretol)
Oxcarbazepine (Trileptal)
Valproate (Depakene)
Lamotrigine (Lamictal)
Gabapentin (Neurontin)
Topiramate (Topamax)
Olanzapine (Zyprexa)
Lithium (Eskalith)
Methylphenidate (Ritalin, Concerta)
Amphetamine (Adderall)
Lisdexamfetamine dimesylate (Vyvanse)
Transdermal
(Emsam)
Atomoxetine
(Strattera)
Mirtazapine (Remeron)
Current and Previous Psychiatrists/Therapists:
Provider Name and Location
Dates/Duration of Seeing Provider
Treatment Received
1
2
3
4
5
6.
Have you ever been hospitalized for a psychiatric reason?
No
Yes
If so, please list your hospitalizations:
Reason for Hospitalization
Date of Hospitalization
Location
Length of Treatment
1
2
3
4
5
Have you tried any of the following depression treatments?
ECT
Ketamine
Psychadelics
None
Medical History
This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every questions to the best of your ability.
Please select all of the following that apply to you:
Cancer
Rheumatic Fever
Lupus or Autoimmune Disease
Arthritis or Rheumatism
Chronic Pain or Complex Regional Pain
Disc Disease
Stomach Ulcer
Gastroesophageal Reflux
Irritable Bowel Syndrome
Colitis
Liver Disease
Hepatitis or Jaundice
Cardiovascular Disease or Heart Failure
Heart Attack or Myocardial Infarction
Coronary Artery Disease/Arteriosclerosis
Diabetes/High Blood Sugar
Low Blood Pressure
High Blood Pressure
Under Active Thyroid
Overactive Thyroid
Anemia
Tuberculosis
Asthma
Hay Fever or Seasonal Allergies
Hives or Skin Rashes
STD/ Venereal Disease
Sexual or Erectile Disfunction
Bladder Problems
Kidney Disease/Kidney Stones
Migraine/Tension Headaches
Fainting Spells
Seizures or Convulsions
Parkinson's Disease
Dementia or Alzheimer's Disease
Glaucoma
Fibromyalgia
Lyme Disease
Other
If selected other, please elaborate:
Please list your current Medical Medications/Vitamins/Supplements:
Name of Medication
Strength of Medication
Date Began
Reason for Taking
1
2
3
4
5
6
7
8
9
10
Who is your Current Primary Care Physician?
Do you see any specialty doctors? (cardiologists/neurologists/etc..) List name and Location
Do you have any Allergies?
Have you ever been hospitalized?
Yes
No
If so, please list your hospitalizations:
Reason for Hospitalization
Date of Hospitalization
Location
Treatment Received
1
2
3
4
5
6
7
8
9
10
Have you ever gotten Surgery?
Yes
No
If so, please list your surgeries :
What surgery did you have done?
Date of Surgery
Location
1
2
3
4
5
6
7
Have you ever Hit your Head or been Hit on the Head? (think about incidents that have occurred at any age)
Yes
No
Have you ever had a brain injury?
No
Yes
If yes, please detail
Have you ever had a seizure?
Yes
No
If yes, please elaborate
Social History
Marital Status
Single
Married
Engaged
Divorced
Separated
Remarried
Cohabiting
Widowed
Do you have any children?
Yes
No
If yes, how many and how old?
Highest Degree Obtained
High School Diploma
Associates Degree
Bachelors Degree
Masters Degree
Doctoral Degree
Other
Dominant Hand
Left
Right
Ambidextrous (both)
Do you drink Alcohol?
No
Yes
If yes, how often and how many drinks?
Do you smoke/vape?
No
Yes
If yes, how much do you smoke?
Do you currently use any recreational drugs?
No
Yes
If yes, what drugs?
Have you ever abused drugs/alcohol before?
Yes
No
If yes, what drugs?
In the last four (4) weeks, select any of the following that you have been bothered by:
Worrying about your health
Your weight or how you look
Little or no sexual desire or pleasure during sex
Difficulties with your significant other
Stress related to taking care of family
Stress at work, school, or outside of the home
Financial problems or worries
Having no one to turn to when you have a problem
Something bad that happened recently
Thinking or dreaming about something terrible that happened to you in the past
Learning disability (Dyslexia, ADHD)
Unusually sensitivity to common noises such as someone eating, computer typing, pen clicking, etc.
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