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Preconsultation Form
Step 1 of 12 - Basic Information
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First Name
*
Last Name
*
Phone
*
Email
*
Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
*
Female
Male
Prefer not to say
Marital Status
*
Single / Never Married
Married / Partnered
Divorced / Separated
Widowed
Living Situation
*
I live alone
I live with someone
Who do you live with?
*
Insurance Carrier
*
Prescribing Psychiatrist
Name
*
Phone
*
Date Since Under Care
*
Best Estimate
Therapist
Name
*
Phone
*
Date Since Under Care
*
Best Estimate
Primary Care Physician
Name
*
Phone
*
Date Since Under Care
*
Best Estimate
Education
*
Graduated High School
Technical Training
Some College
College Graduate
Graduate education
Other
Are you employed?
*
Yes
No
I have a disability that prevents me from working
Where are you employed?
*
I have been disabled since and due to:
*
I have been unemployed since:
*
Where were you born?
*
Who raised you during your childhood?
*
Do you have any family members with psychiatric disorders or substance use? If so, what kind of treatment have they had?
*
Any family history of suicide or suicide attempt?
*
Have any of your family members been hospitalized in a psychiatric clinic?
*
Any family history of treatment with ECT or TMS?
*
If you have had surgery, list the date(s) and type of operation(s)
*
Date
Type of Operation
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List any current medical conditions
*
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Do you have a history of past seizures or epilepsy?
*
Yes
No
When is the last time you had a physical exam or "check-up" with a primary care doctor?
*
Do you have any metal surgically implanted or embedded in your body?
*
Yes
No
What is your understanding of your diagnosis?
*
Major Depressive Disorder
Which best describes your LIFETIME experience with depression?
*
"Episodes" of more severe symptoms (at least 2 weeks) with some periods between episodes when I feel better / relatively normal
Chronic Symptomps that never get 50% bettter
When did your current episode of depression begin?
*
Did/do you have a substance abuse disorder?
*
Yes
No
Did/do you have a history of an eating disorder?
*
Yes
No
Did/do you have a history of self-mutilation?
*
Yes
No
Please explain
*
Did/do you have a history of suicide attempts or gestures?
*
Yes
No
Please explain
*
How old were you when you first experienced symptoms?
*
Describe the symptoms
*
When did you first get treatment?
*
Age or year
Describe first treatment (age or year; medication or therapy)
*
Do you have a history of prior ECT or TMS treatment? If yes, please indicate below:
*
Treatment (ECT or TMS)
Dates
Where did you obtain treatment?
Number of treatments
Response
Use the plus (+) icon to add new items
Please indicate any and all of the psychiatric medications you have taken for your depression
*
Medication
Max Dose
Estimated Start Date
Estimated Duration
Response
Side Effects
Write Yes if Current
Celexa (citalopram)
Lexapro (escitalopram)
Prozac (fluoxetine)
Paxil (paroxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Trintellix (vortioxetine)
Viibryd (vilazodone)
Cymbalta (duloxetine)
Effexor (venlafaxine)
Pristiq (desvenlafaxine)
Fetzima (levomilnacipra)
Other Antidepressants
Serzone (nefazodone)
Buspar (buspirone)
Desyrel (trazodone)
Remeron (mirtazapine)
Wellbutrin SR (bupropion)
Wellbutrin XL
Ritalin
Dexedrine
Adderall
Vyvanse
Lithium
Thyroid hormone
Lamictal (lamotrigine)
Memantine
Topamax
Valproic Acid
Risperdal (risperidone)
Zyprexa (olanzapine)
Seroquel (quetiapine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Invega (paliperidone)
Latuda (lurasidone)
Rexulti (brexpiprazole)
Vraylar (cariprazine)
Saphris (asenapine)
Fluphenazine
Thiothixene
Haloperidol
Nardil (phenelzine)
EMSAM (selegiline)
Parnate(tranylcypromie)
Marplan (isocarboxazid)
Amoxapine
Clomipramine
Desipramine
Doxepin
Maprotiline
Nortriptyline
Amitriptyline
Trimipramine
Use the plus (+) icon to add new items
Have you had any history of non-medication interventions?
*
Past Outpatient Psychotherapy
Intensive Outpatient or Partial Hospital Programs
Hospital Admission(s) for Psychiatric Care
Hospital Admission(s) for drug/alcohol detox
Drug/Alcohol Rehab programs
Research/investigational treatments (i.e. Ketamine, tDCS, etc.)
Please describe any history of non-medication interventions
Please give as much detail as you can (Dates, Names, Focus of Care).
Past Outpatient Psychotherapy
*
Include name, dates of treatment, and type of treatment (i.e. CBT, Interpersonal, Psychodynamic, etc.)
Intensive Outpatient of Partial Hospital Programs
*
Hospital Admission(s) for Psychiatric Care
*
Hospital names and dates
Hospital Admission(s) for drug/alcohol detox
*
Drug/alcohol rehab programs
*
Research/investigational treatments
*
i.e. Ketamine, tDCS, etc.
Even if no treatment has ever fully resolved your depression, which treatment has worked BEST for relieving symptoms?
*
Have you ever experienced full recovery (completely better for at least a year) from an episode of depression? If yes, please describe:
*
Current Symptoms
*
Sleep Disturbance: Insomnia, awakening throughout the night, awaken too early
No Interest in hobbies, leisure activities, recreational activities
Appetite disturbance
Trouble concentrating or making decisions
Feelings of apathy or lack of motivation
Low energy, easy fatigue
Feeling anxious, tense, nervous, or fearful
Physical symptoms: Pain in Body, Headaches, Stomach upset, etc.
Mood is sad, easily tearful
Irritable mood or frequent mood swings, over-reactive mood
Negative self-esteem, feeling worthless
Internal agitation, feeling the need to pace or fidget
Guilt feelings, Feeling like a burden to others
Slow thinking, slow movement, or slow talking
Hopelessness, thoughts of giving up
Intrusive negative thoughts or unpleasant memories
Trouble socializing with others, urge to isolate self
Easily overwhelmed; unable to cope with minor stressors
Staying in bed, napping during the day, sleeping to “escape”
Preoccupation with body, disease, illness, death
Paranoia or feelings that someone might harm you or monitor you
Hearing a voice or sounds that others don’t hear
Thinking about or planning suicide; Desire to go to sleep forever
Craving or eating junk food, carbohydrates; poor nutritional habits
Other IMPORTANT SYMPTOMS not listed above?
Check all that apply
Other symptoms
*
Please rate your Mental Health and Functioning Level on this scale:
*
Current rating
Highest rating you've ever experienced
(0 = Worst ever…..100 = ”Normal” or optimal mental heath)
Anything else you think I should know?
*
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