PTSD Study - Intake Form

1
Legal Full Name* This field is required.
2
Preferred Name
3
Date of Birth
Date
Year
Month
Day
4
Gender* This field is required.
Male
Female
Non-Binary
Self-describe
Prefer not to say
5
Sex assigned at birth* This field is required.
Please Select
Please Select
Male
Female
Intersex
Prefer not to say
6
Phone Number* This field is required.Primary Number
Area Code
Phone Number
7
Phone NumberAlternate Number
Area Code
Phone Number
8
Email* This field is required.
example@example.com
9
Mailing Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Preferred Contact Method* This field is required.
Please Select
Please Select
Phone
Text
Email
11
Emergency Contact Information* This field is required.
Emergency Contact - Name
Emergency Contact - Relationship
Emergency Contact - Phone Number
12
How did you hear about this study?* This field is required.
Please Select
Please Select
VA
Primary Care Provider
Mental- Health Provider
Cognitive FX Patient
Website
Social Media
Flyer
Community Outreach
Other
13
Primary Care Provider and Clinic Name
14
Mental- Health Provider and Clinic Name
15
Preferred Language* This field is required.
16
Current Age* This field is required.
17
Age within Range
18
Have you been diagnosed with PTSD by a clinician?* This field is required.
YESNO
19
Approximate duration of PTSD symptoms* This field is required.
Please Select
Please Select
< 3 Months
3-6 Months
6-12 Months
1-5 Years
> 5 Years
20
Are you taking psychiatric medication(s)?* This field is required.
YESNO
21
If yes, has the dose been stable for 6 weeks or more?* This field is required.
Yes
No
Not Applicable
22
Any medication changes planned in the next 4 months?* This field is required.
Yes
No
Not Applicable
23
Are you able to read and write in English?* This field is required.
YESNO
24
Can you attend appointments 5 consecutive weekdays (Mon-Fri, 8am - 5pm)?* This field is required.
YESNO
25
Are you able and willing to provide written informed consent?* This field is required.
YESNO
26
Do you have any of the following?* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Cochlear implant?
Deep brain stimulator?
Vagus nerve stimulator?
Aneurysm clip or coil?
Stent in neck or brain?
Implanted electrodes?
Cochlear implant?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 6
27
Other implanted electronic device or ferromagnetic metal in head/neck (incl. shrapnel)?* This field is required.
Please Select
Please Select
Yes
No
Yes or No
Please Explain
28
Personal history of seizure? (excluding single childhood febrile)* This field is required.
Please Select
Please Select
Yes
No
Yes or No
Please Explain
29
First-degree relative with epilepsy? * This field is required.
YESNO
30
History of head trauma with loss of consciousness >10 minutes? * This field is required.
Please Select
Please Select
Yes
No
Yes or No
Please Explain
31
History of stroke, brain tumor, or other neurological disorder? * This field is required.
Please Select
Please Select
Yes
No
Yes or No
Please Explain
32
Prior neurosurgery involving brain tissue? * This field is required.
Please Select
Please Select
Yes
No
Yes or No
Please Explain
33
Pacemaker, ICD, or other implanted electronic medical device?* This field is required.
Please Select
Please Select
Yes
No
Yes or No
Please Explain
34
Insulin pump, neurostimulator, programmable shunt, or implanted port?* This field is required.
Please Select
Please Select
Yes
No
Yes or No
Please Explain
35
Any surgical clips, plates, screws, or hardware?* This field is required.
Please Select
Please Select
Yes
No
Yes or No
Please Explain
36
History of claustrophobia in MRI or enclosed spaces?* This field is required.
Please Select
Please Select
Yes
No
Yes or No
Please Explain
37
Body weight (lbs)* This field is required.
38
Is your chest/abdominal circumference larger than 60 cm? * This field is required.
YESNO
39
Could you currently be pregnant or are you breastfeeding? (If applicable)* This field is required.
Yes
No
Not Applicable
40
Consent to urine pregnancy test at screening (if applicable)* This field is required.
Yes
No
Not Applicable
41
MRI Safe?
42
Lifetime diagnosis of schizophrenia, schizoaffective, or delusional disorder?* This field is required.
YESNO
43
Lifetime diagnosis of bipolar I disorder?* This field is required.
YESNO
44
In the past month, has alcohol or drug use significantly impaired your life or health?* This field is required.
Please Select
Please Select
Yes
No
Yes/No
Please Explain
45
Current thoughts of suicide with intent or plan?* This field is required.
YESNO
46
Psychiatric inpatient hospitalization within past 3 months?* This field is required.
Please Select
Please Select
Yes
No
Yes/No
Date
47
Started new PTSD-specific psychotherapy within past 3 months?* This field is required.
Please Select
Please Select
Yes
No
Yes/No
Date
48
Currently enrolled in another interventional research study?* This field is required.
Please Select
Please Select
Yes
No
Yes/No
Study Name
49
Prior TMS treatment within past 3 months?* This field is required.
Please Select
Please Select
Yes
No
Yes/No
Date
50
Year PTSD symptoms began (approximate)* This field is required.
51
Have you previously received treatment for PTSD?* This field is required.
YESNO
52
Prior PTSD treatments Select all that apply
CBT/CPT
PE
EMDR
Medication
Group
None
Other
53
Are you currently in ongoing therapy for PTSD?* This field is required.
YESNO
54
If yes, approximate start date of current therapy
Date
Year
Month
Day
55
Any military or first-responder service?
YESNO
56
(Optional) Brief description of nature of trauma — single phrase only
57
Current chronic medical conditions* This field is required.
58
Current medications (Name, Dose, Duration)
Huge
Large
Normal
Small
Ok
Ok
59
Known drug allergies* This field is required.
60
Any major medical events or hospitalizations in the last 3 months* This field is required.
61
Any pending surgeries or procedures in the next 4 months * This field is required.
62
Medical Conditions to review for possible Exclusion
63
Inclusion Met
64
Exclusion Met
65
I confirm answers above are accurate to best of my knowledge.* This field is required.
YESNO
66
I authorize Cognitive FX to contact me about study scheduling.* This field is required.
YESNO
67
.I authorize release of relevant medical records from listed providers
YESNO
68
HIPAA authorization signed (this is a separate form)* This field is required.
YESNO
69
Participant Full Name
First Name
Last Name
70
Date
Date
Month
Day
Year
71
Participant Signature
Should be Empty: