TMS/SPRAVATO Pre-Appointment Form

First name

Last name

Date of Birth

Email address

Phone number

What insurance do you have?

Please note that we DO NOT take any HMOs in the office

Date of Onset of Depressive Symptoms

An exact date is not required. Please provide the best month and year by using the 1st of the month as the date. If your symptoms started in April 2020, please choose 04/01/2020

Which of the following augmenting agents have you tried? Please be able to provide dates and dosages at your scheduled appointment

Seroquel (quetiapine)

Zyprexa (olanzapine)

Abilify (aripiprazole)

Invega (paliperidone)

Geodon (ziprasidone)

Risperdal (risperidone)

Buspar (buspirone)

None of the above

Have you ever seen a therapist? Please be able to provide the dates and name of therapist

Yes, I am currently seeing a therapist regularly

Yes, but I am not currently in therapy

No, I have never met with a therapist

Have you tried any of the following treatments before? Please be able to provide dates of treatment at your scheduled appointment

Transcrianial Magnetic Stimulation (TMS)

Electroconvulsive Therapy (ECT)

SPRAVATO (intranasal esketamine)

IV Ketamine Infusions

None of the above

Over the last two weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things

Not at all

Several days

More than half the days

Nearly every day

2. Feeling down, depressed, or hopeless

Not at all

Several days

More than half the days

Nearly every day

3. Trouble falling or staying asleep, or sleeping too much

Not at all

Several days

More than half the days

Nearly every day

4. Feeling tired or having little energy

Not at all

Several days

More than half the days

Nearly every day

5. Poor appetite or overeating

Not at all

Several days

More than half the days

Nearly every day

6. Feeling bad about yourself - or that you are a failure or have let yourself down or your family down

Not at all

Several days

More than half the days

Nearly every day

7. Trouble concentrating on things, such as reading the newspaper or watching television

Not at all

Several days

More than half the days

Nearly every day

8. Moving or speaking so slowly that other people could notice. Or the opposite - being so figety or restless that you have been moving around a lot more than usual

Not at all

Several days

More than half the days

Nearly every day

9. Thoughts that you would be better off dead, or of hurting yourself

Not at all

Several days

More than half the days

Nearly every day

Is there anything else you would like us to know?

Insurance Card & Photo ID Upload If you would like, you may provide us a copy of your insurance card and photo ID so we may check information relating to your benefits, eligibility, or pre-authorization status for treatment

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