TMS SCREENING

Harmonious Mind (Psychiatric and Counseling Services)

5189 W. Woodmill Dr., St.30, Wilmington, DE 19808. On the Web: www.HarmoniousMind.com

Tel: 302.633.6001 Fax: 302.295.6289 SMS/Text: 302.565.4818 Email: Support@HarmoniousMind.com

Patient Name

First and Last Name

Date of Birth

Phone Number

302-123-1234

Email address

Patient Home Address

Street, City, State, Zip Code.

Insurance Name

Insurance Member ID

Current Diagnosis of MDD (Major Depressive Disorder)?

Yes No

TMS Treatment

The patient has done TMS before.

I, the patient has already determined I definitely want TMS treatment.

I am inquiring and want more information about TMS.

List of Trials of Failed Drugs/Medications: (Please send Medication History as .pdf via email)

Medication Name and Dose

Drug Class

Date Tried

Medication Name and Dose

Drug Class

Date Tried

Medication Name and Dose

Drug Class

Date Tried

Medication Name and Dose

Drug Class

Date Tried

Medication Name and Dose

Drug Class

Date Tried

Currently in Cognitive Behavioral Therapy or has had CBT Treatment?

Yes No

Date of Last Appointment

Date of Next appointment

PhQ9 (national standardized rating scale) Score

Are any of the following conditions present?

Seizure Disorder (past/present)

resence of acute of chronic psychotic symptoms or disorders in the current depressive episode.

Neurological Conditions that include epilepsy history, cerebrovascular disease, dementia, increased intracranial pressure, repetitive or severe head trauma, or primary or secondary tumors I the central nervous system.

Excessive use of alcohol or illicit substances within the last 30 days.

No response by patient to a prior course of TMS.

The patient has received a separate acute phase TMS treatment in the past 6 months.

NONE OF THE ABOVE ARE PRESENT.

Signature

Date Signed

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