Neural Health Therapies TMS Initial Questionnaire

Neural Health TMS

Patient Health History
Identifying Information
Full Name*

PrefixFirst NameLast Name
Date of Birth*

MonthDayYear
Occupation
Gender*
Marital Status
Children?
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number*

Area CodePhone Number
Okay to leave voicemail?
E-mail
Welcome to Our Practice
How did you hear about Neural Health Therapies?*
What prompted you to seek consultation for TMS therapy?*
Emergency Contact
Emergency Contact Name/Relationship*
Phone Number*

Area CodePhone Number
Current Providers
Referring Provider Name and Phone #:
Current Psychiatrist/Prescriber Name and Phone#:
Current Therapist Name and Phone#:
Current Primary Care Doctor Name and Phone#:
Psychiatric History
Current Psychiatric Diagnoses:
History of Psychiatric Hospitalization? Please include dates.
Please describe current symptoms and duration:
History of psychotic symptoms/hallucinations?
History of self-injury?
History of suicidal ideation?
History of suicide attempts?
Trauma history?
Previous psychiatric medications/treatments tried (medications, therapies, previous TMS, ECT, etc. Please include any adverse reactions) ** Please include max dosages of medications and dates
Medical History
Please list current medical problems:
Current Medications (Please include all medications and supplements frequency and dosage):
Please indicate if you have had any of the following:

History Hypertension/High Blood PressureLow Blood PressureCardiovascular Disease/MIHeart ConditionAneurysmSyncope/FaintingKidney DiseaseUrinary/Bladder IssuesSeizure DisorderHead InjuryHead/brain tumorGI IssuesStrokeGlaucomaThryoid IssuesCancerAny Blood DisordersDiabetesAsthma/Breathing problemsHepatitisLiver DiseasePregnant/NursingHead /brain tumorOther
Do you have any non-removable metal object around your head (including pacemakers or any other implanted medical devices?)
Substance Abuse History:

TobaccoAlcoholMarijuanaOpiatesHallucinogensCocaine/StimulantsOther
How many alcoholic drinks do you consume per day?
Any other information you feel is important for us to know?
By signing below you certify that you have completed this questionnaire accurately to the best of your knowledge.
Signature*

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Date

MonthDayYear
Date
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Identifying Information

Welcome to Our Practice

Emergency Contact

Current Providers

Psychiatric History

Medical History