Electroconvulsive Therapy Assessment Form
Complete this form to assess candidacy and plan for ECT treatment. Please answer all questions accurately based on the patient's clinical presentation.
Primary Indication for ECT
*
Major depressive episode (severe)
Mania
Catatonia
Psychotic symptoms
Other (please specify)
Current Psychiatric Diagnosis
*
Previous Treatments Attempted
*
Antidepressant medications
Antipsychotic medications
Mood stabilizers
Psychotherapy
Other (please specify)
Medical History (relevant comorbidities)
*
Are there any known contraindications to ECT?
*
No known contraindications
Recent myocardial infarction
Unstable cardiac disease
Increased intracranial pressure
Other (please specify)
Current Medications (list all active medications)
*
Risk Factors Checklist
*
History of cardiovascular disease
History of seizures
Pregnancy
Recent stroke
No significant risk factors
Expected Benefits and Risks (clinician's assessment)
*
Readiness for ECT (rate the patient's readiness and understanding)
*
1
2
3
4
5
Submit Assessment
Should be Empty: