houstonwesttms.com - Initial Evaluation Form

Patients Name

Nickname

Age

Sex

MaleFemaleOther

Self Identified Race

Date

1. Please list the reasons you have sought a psychiatric consultation at this time?

2. Sleep: My sleep is normal

YesNo

If not normal, check problem; I have trouble:

falling asleepstaying asleepwaking up too earlysleeping too much

3. Energy: (select one) My energy is normal;

too lowtoo high

4. Appetite: (select one) My appetite is

normaldecreasedincreased

Have you lost or gained weight recently?

YesNo

If so, how much?

5. Have you ever become desperate enough to consider:

Rows	Yes	No
Death?
Hurting yourself?
Suicide?
Hurting someone?
Homicide?
Divorce?
Destroying something?
Running away?
Doing something crazy?
Using Drugs?

6. How were you referred to Dr. Drell?

7. May we thank and/or share information with you referral source?

YesNo

If Yes, please place your initials here

8. Have you seen any other psychiatrists or therapists prior to this appointment?

YesNo

If yes, please list their names and addresses, and whether or not give us permission to request information and records from the physician/therapist if necessary.

9. Have you ever been hospitalized for psychiatric problems, alcohol, or substance abuse? If so, please fill out the following?

10. Have you taken any psychiatric medications in the past? These might include the following: Elavil, Doxepin, Pamelor, imipramine, Prozac, Zoloft, Paxil, Lexapro, Celexa, Luvox, Serzone, Ativan, Klonopin, Librium, Haldol, Navane, Thorazine, Mellaril, Zyprexa, Risperadal, Seroquel, Geodon, Abilify, Lamictal, Tegretol, Topamax, Depakote, etc. if so, please list them below.

11. Who is your primary medical doctor?

Address

Date last seen

Do you give permission for us to discuss your case with your primary medical doctor if clinically necessary?

YesNo

Initial here please

12. Do you have any current health problems? Please list

13. Please write your height

Weight

Ideal Weight

Waist size in inches (as a baseline for medication related weight change)

14. Do you have a family history of Diabetes, Heart Disease, sudden death, prolongedQT Syndrome, Cardiomyopathy, thyroid problems, ETC. ?

15. Are you currently on any medications?

YesNo

If yes, please list them below:

Rows	Medication	Dosage	Directions
1
2
3
4
5
6
7
8

16. Are you taking any vitamins, herbal products, dietary supplements, alternativemedications or weight loss preparations? Please list them below:

17. Are you allergic to any medications? If yes, please list:

18. Have you had any surgeries in the past? If so, please list the type of surgery and date:

19. Do you suffer from chest pain, shortness of breath, palpitations, or dizziness on exertion?

YesNo

20. Have you ever fainted or almost fainted (especially without exercising)?

YesNo

21. Gave you had any head injuries, loss of consciousness or seizure disorders?

YesNo

22. Do you have tics, facial twitches, or tremors?

YesNo

Do you have a family history of these?

YesNo

23. Do you have a history of glaucoma?

YesNo

23. Do you have a history of glaucoma?

YesNo

Is it being treated?

24. Do you have a pacemaker, implantable pumps or metal appliances?

YesNo

25. Do you obsess on food, overeat compulsively, restrict what you eat, or vomit (purge) intentionally?

YesNo

26. Are you pregnant or do you plan to get pregnant soon?

YesNo

When was your last menstrual period?

Has anyone in your family had emotional or psychiatric problems, drug/ alcohol abuse problems, or suicide? (include grandparents, aunts, uncles, parents, siblings, child- ren or spouse). Please list and explain what problems and treatments they have received

28. Please list the name and age of your parents, spouse, children, siblings, and significant other, as well as their occupations.

Rows	Relative/age emotional problems	Specific drug/alcohol or received	Treatment received
Mother
Father
Siblings
Spouse/significant
Childrens

29. Did your parents ever divorce or separate?

YesNo

If yes, how old were you?

Who did you live with?

30. Where were you born and raised?

31. Have you been a victim of physical, sexual, or emotional Abuse?

YesNo

If so, by whom?

Has anyone at home hit or harmed you?

YesNo

Do you feel safe at home?

YesNo

32. Were either of your parents sexually or physically abused or did your mothersuffer from ptsd (post traumatic stress disorder)?

YesNo

33. Have there been any significant stressors in the last 12 months (debt, divorce,illness, moves, etc.)?

34. Who currently lives in your household?

35. Do you consider yourself Heterosexual

HeterosexualHomosexualBi -sexual

Married?

Divorced?

Separated?

Widowed?

37. What was your longest marriage?

38. When were you growing up, did you have a normal development (walk ontime/talk on time, etc.)?

39, What is your highest educational level of completed education?

40. Where do you work or go to school?

41. How long have you been at your current job?

42. How long was your longest job?

43. Were you in the military?

If so, when and which branch?

44. Do you currently have any stressors related to finances?

45. Do you have any legal problems?

46. What is your religious preference?

Are you actively involved?

47. What are your hobbies? What do you do for FUN?

Substance

Rows	Amount	Frequency	Duration	1st use	Last use
Caffeine
Tobacco
Alcohol
Marijuana
Opiates /narcotics
Amphetamines
Cocaine
Hallucinogens
Synthetic drugs/bath salts/incense
OTHERS

49. Select 'Yes' or 'No'

Rows	Yes	No
Do you drink alcohol in the morning?
Have you ever had a DWI or public intoxication charge?
Do you feel you are a normal drinker or non drinker currently?
Was there a time in the past when you felt you used alcohol or drugs excessively?
Do friends/relatives think you're a normal drinker or non-drinker?
Have you ever lost friends or girl/boyfriends because of your drinking?
Have you ever gotten into trouble at work because of drinking?
Have you ever neglected your obligations, family, or your work for 2 or more days in a row because of your drinking?
Have you ever had delirium tremens (DTs), severe shaking, hearing voices, or seen things that weren't there after heavy drinking?
Have you ever gone to anyone for help for your drinking or drug usage?
Have you ever been in a hospital because of drinking or drug usage?
Have family or friends ever expressed concern over your use of drugs?
Have you ever been arrested for any offense involving drugs?
Have you ever been treated for chemical dependency?
Have you overdosed on drugs (accidentally or on purpose) ?

Have you ever attended a 12 step meeting (AA, NA CA, ALANON, etc.)

YesNO

IF yes, which ones?

50. Select 'Yes' or 'No'

Rows	Yes	No
A. Do you often have trouble wrapping up the final details of a project once the challenging part is done?
B. Do you often have difficulty getting things in order when you have to do a task that requires organization?
C. Do you often have problems remembering appointments or obligations?
D. Do you often procrastinate getting started when a task requires a lot of thought?
E. Do you often feel restless with your hands or feet when you have to sit down for a long time?
F. Do you often feel restless or overly active and compelled to do things like you were driven by a motor?

51. Do you have any intrusive, unwanted or repetitive thoughts that you cannot control (obsessions)?

YesNo

52. Do you wash your hands excessively or repeatedly check things (compulsive behaviors)?

YesNo

53. Do you do needless counting or repeating?

YesNo

54. Do you have a history of:

Promiscuity?Compulsive spending?Reckless driving?Gambling?

55. Do you own a handgun?

YesNo

When did you purchase/obtain it?

56. Do you agree with the following statements?

Rows	Yes	No
Suicide is a normal behavior.
Sometimes suicide is the only escape from life's problems.
In general, suicide is an evil act not to be condoned.
I have a religious/moral prohibition of suicide.

57. Please list your strengths (E.G. positive personality traits, talents, what is good about you?):

58. Please list your weaknesses or limitations:

59. Please list any personal changes you would like to make:

Signature

Date

Rows	Yes	No
...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
...you were so irritable that you shouted at people or started fights or arguments?
...you felt much more self-confident than usual?
...you got much less sleep than usual and found you didn’t really miss it?
...you were much more talkative or spoke much faster than usual?
...thoughts raced through your head or you couldn’t slow your mind down?
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
...you had much more energy than usual?
...you were much more active or did many more things than usual?
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
...you were much more interested in sex than usual?
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
...spending money got you or your family into trouble?

Rows	Not at all	Several days	More than half the days	Nearly everyday
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling 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 fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

Rows	Not at all sure	Several days	Over half the days	Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

New Patient Psychiatric Questionnaire

Chief Complaint

Past Psychiatric History

Medical History

Family Psychiatric History

Social History

36. How many times have you been:

48. Drug/Alcohol and Tobacco History

Miscellaneous

THE MOOD DISORDER QUESTIONNAIRE

PATIENT HEALTH QUESTIONNAIRE

Generalized Anxiety Disorder 7 (GAD-7) Scale

TMS THERAPY EXCLUSION CRITERIA