Vital TMS Intake Form for TMS 2023

Vital TMS Therapy & Mental Health Services

TMS Intake Form
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Email Address
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?
Other:
Please specify, it helps us, help more people!
Gender Identity: (Optional)
Preferred Pronouns (Optional)
Sexual Orientation (Optional)
Ethnicity (Optional)
Marital Status (Optional)
Emergency Contact Person
Emergency Contact Person Phone #
Current Primary Care Doctor's Name
Current Primary Care Doctor's Phone #
Current Mental Health Clinician's Name
i.e. Phsychiatrist, Mental Health Nurse Practioner
Current Mental Health Clinician Phone #
Current Therapist's Name
i.e. Psychologist, Counselor / Social Worker/ LiCSW or PHD
Current Therapist Phone #
INSURANCE INFORMATION
Primary Insurance Company Name
Insurance Policy or Member ID Number
Primary Insurance Group Number
Are you the policy holder?
Policy Holder's Name
Policy Holder's Address
Policy Holder's Date of Birth
Your Relationship to the Policy Holder?
Child, Husband, Wife, Partner, Other
Do you have a secondary insurance?
Secondary Insurance Company Name
Secondary Insurance Company Phone #
Are you enrolled in the Medicare program?
Are you enrolled in the Medicaid program?
Are you enrolled in the Veteran's Affairs (VA) program?
Mental Health History

Please complete the following information and our team will go through this in more detail with you at your TMS consultation.
Approximately when did your current depressive symptoms start?
Do you have any previous mental health hospitalizations?
What was the approximate date of your most recent mental health hospitalization?
How many mental health hospitalizations have you had?
Are you CURRENTLY under the care of a Psychiatrist or Psychiatric Nurse Practioner who prescribes you medication?
In the past, have you attended talk therapy with a therapist, counselor or Psychologist?
Do you CURRENTLY attend talk therapy with a therapist, counselor or Psychologist?
What is the approximate date that you last attended talk therapy?
Please Select ALL of your Current Symptoms
Pertinent Medical History
Do you have any metal objects or implantable devices in or around the head (e.g. cardiac defibrillator / pacemaker, cochlear impant, other)?
If "YES" or "UNSURE" to the presence of metal objects or devices, please provide as much detail as possible in the space provided below:
Do you have any History of Seizures?
If "YES" or "UNSURE" to the presence of metal objects or devices, have you had an MRI in the past and is it safe for you to have a MRI now?
Please bring your impant card with you to the consultation, if you have it.
Do you have any Allergies?
If "YES" to allergies, please list them and the reaction( i.e penicillin gives me a rash) :
Please list ALL of your Medical Diagnoses:
Please list ALL previous surgeries with the year the surgery was performed.
Family History

Do you have a family history of mental health issues?
Please list the family member(s) and the disorder(s)
Social History
Do you live alone or with others
If you live with others, who do you live with?
What is your occupation?
Employment Status?
Have you ever smoked cigarettes?
Currently?
How many packs per day?
How many years?
In the Past?
How many packs per day?
How many years?
When did you quit?
Vaping?
Marijuana?
If yes, How often?
Alcohol?
If yes, How often and how much?
Illicit drug use?
Have you ever considered yourself to have a problem with alcohol or drugs?
If yes, approximately how long has it been since you last used alcohol or drugs?
Antidepressants

Carefully examine the list below, please select both CURRENT and PREVIOUS medications tried:
SSRI's
Please include the Dosage and timeframes for the option(s) selected
SNRI's
Please include the Dosage and timeframes for the option(s) selected
TCA's
Please include the Dosage and timeframes for the option(s) selected
MAOI's
Please include the Dosage and timeframes for the option(s) selected
NDRI
Please include the Dosage and timeframes for the option(s) selected
SM's
Please include the Dosage and timeframes for the option(s) selected
Other antidepressants
Please include the Dosage and timeframes for the option(s) selected
Mood Stabilizers
Please include the Dosage and timeframes for the option(s) selected
Anti-Psychotics / Mood Stabilizers
Please include the Dosage and timeframes for the option(s) selected
Sedative / Hypnotics
Please include the Dosage and timeframes for the option(s) selected
ADHD / Stimulants
Please include the Dosage and timeframes for the option(s) selected
Anti Anxiety
Please include the Dosage and timeframes for the option(s) selected
Please list any other medications not on this list:
PHQ-9

Patient Health Questionnaire-9- Self Rating Scale
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest of pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired of having little energy
5. Poor appetite or overeating
6. Feel bad about yourself or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite- being so figety or resltess that you have been moving around a lot more than usual.
9. Thoughts that you would be better off dead, or of hurting yourself
If you check 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?
Result (office use only)
GAD-7

Generalized Anxiety Disorder -7- Self Rating Scale
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much or about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
If you check 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?
Result (office use only)
Signature
Date

MonthDayYear
Date
Should be Empty:

Vital TMS Therapy & Mental Health Services

INSURANCE INFORMATION

Mental Health History

Please Select ALL of your Current Symptoms

Pertinent Medical History

Family History

Social History

Antidepressants

PHQ-9

GAD-7