TMS Medical History

TMS Medical History

The following questions are intended to elicit basic background information prior to our first visit. Much of this information will be discussed in greater detail during your appointment. Please leave questions blank if they do not pertain to you or if you do not feel comfortable answering. Please be sure to fill out the entire form and press the "Submit" button at the end.
Who referred you?
What is your primary concern?
Name

First NameMiddle NameLast Name
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hometown
Street Address
City
State
Zip
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email
example@example.com
Highest Level of Education
Place of Employment
Occupation/Title
Hours/Week
If not working, are you

Other
If you receive disability or SSI, for what disability?
and for how long?
Relationship Status
Height
Weight
Preferred Pharmacy (Name and Address)

EMERGENCY CONTACTS:
First Name
Address (if different from above)
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Relation
Place of Employment
Second Name
Address (if different from above)
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Relation
Place of Employment

PSYCHIATRIC/PSYCHOLOGICAL/MEDICAL HISTORY

List all doctors and mental health professionals who have examined and/or treated you. Please give name and phone number for each.
Family Physician/Primary Care Physician
Previous Psychiatrist(s)
Therapist(s) or Counselor(s)
Other Physician(s)
Other list type of provider and contact
List all previous psychiatric diagnoses given
List all other medical conditions/diagnoses

List medications you have been on in the past (not taking currently) for mood or behavior. Please include length of time taken and dose, if known. Please refer to the medication list at the end of this document, if needed.

Rows	Medication	Dose	Taken for how long?	Reason for stopping
First Medication
Second Medication
Third Medication
Fourth Medication
Fifth Medication
Sixth Medication
Seventh Medication
Eighth Medication

What medication(s) are you taking now? Please include all medications, not just those for mood or behavior. Please refer to the medication list at the end of this document, if needed.

Rows	Medication	Dose	Taken for how long?	Reason for taking
First Medication
Second Medication
Third Medication
Fourth Medication
Fifth Medication
Sixth Medication
Seventh Medication
Eighth Medication

List any allergic reactions to medications

If you have ever been hospitalized, please explain when and for what reason

Rows	Name of Hospital	Year	Reason/Diagnosis
First
Second
Third
Fourth
Fifth

Rows	Mother	Father	Brother(s)	Sister(s)	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
ADHD/ attentional problem
Childhood behavioral problems
Problems with aggression
Learning disability
Failed high school
Intellectual Disability
Autism
Psychosis/schizophrenia
Bipolar Disorder
Depression (greater than 2 weeks)
Suicide
Anxiety or adjustment disorder
Panic disorder
Other mental disorder (describe below)
Tic disorder or Tourette’s
Heart Problem at a young age (<60)
Alcohol Abuse
Substance Abuse
Antisocial behavior (assault/thefts)
Arrests/incarcerations
Physical abuse (victim)
Physical abuse (perpetrator)
Sexual abuse (victim)
Sexual abuse (perpetrator)

TMS Medical History

EMERGENCY CONTACTS: