New Patient Intake Form

General Patient Background - Step 1 of 4

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone

Birth Date (mm/dd/yyyy)

Have you been diagnosed with major depressive disorder?

Have you ever had a head injury (including neurosurgery) or any brain-related injuries?

Have you ever had a seizure?

Do you have any metal in your head such as shrapnel, surgical clips, or fragments from welding?

Do you have any implanted devices such as cardiac pacemakers, medical pumps, or intracardiac lines?

Which of the Following Medications Have You Been Prescribed? (Check all that apply)

alprazolam (Xanax)
buspirone (Buspar)
citalopram (Celexa)
clonazepam (Klonopin)
escitalopram (Lexapro)
fluoxetine (Prozac)
fluvoxamine (Luvox)
paroxetine (Paxil)
paroxetine CR (Paxil CF)
sertraline (Zoloft)
vortioxetine (Trintellix)
vilazodone (Vilbryd)
desvenlafaxine (Prisiq)
duloxetine (Cymbalta)
venlafaxine (Effexor)
venlafaxine XR ( Effexor XR)
levomilnacipran (Fetzima)
milnacipran (Savella)
trazodone (Desyrel)
vortioxetine (Trintelliz)
nefazodone (Serzone)
aripiprazole (Abilify)
eskalith (Lithium)
carbamazepine (Tegretol_
carbamazepine XR (Equettro)
divalproex (Depakote)
lamotrigine (Lamictal)
lorazepam ((Ativan)
brexpiprazole (Rexulti)
oxcarbazepine (Trileptal)
quetiapine (Seroquel)
lurasidone HCL (Latuda)
olanzapine (Zyprexa)
ziprasidone (Geodon)
asenapine (Saphris)
amitriptyline (Elavil)
clomipramine (Anafranil)
desipramine (Norpramin)
doxepin (Sinequan)
imipramine (Tofranil)
nortriptyline (Pamelor)
trimipramine (Surmontil)
lurazidone (Latuda)
bupropion (Wellbutrin)
bupropion XL (Wellbutrin XL)
bupropion SR (Wellbutrin SR)
mirtazapine (Remeron)
nefazodone (Serzone)
phenelzine (Nardil)
selegline (Emsam)
trancycypromine (Parmate)

Of the medications you checked off above, please enter the NAME, dates of use and reason for discontinuing each.

Insurance Carrier

Member Number

Subscriber Name

Are you a good candidate for TMS Therapy?

While TMS offers real hope for persistent depression, not everyone is an ideal candidate for treatment. Complete the simple quiz below to find out if TMS is right for you!

TAKE THE QUIZ AND FIND OUT

Take The Quiz

Click "Next" Button to Proceed Through Quiz.

I have been diagnosed with depression

yes

I am currently experiencing symptoms of depression (sadness, low energy, poor concentration, appetite changes, irritability)

Yes

I have tried or am currently on antidepressant medications.

yes

I have tried talk therapy

yes

I have tried or am currently on 3 or more antidepressant medications

yes

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