TMS Qualification Form

Profile Information & Questionnaires

Pre-Qualification form

Fill out this complimentary look at your mental health so we can assess your needs for TMS, MeRT or Ketamine. We will then send you the information.

Note: This form is not for a psychiatrist. It will be used to get an understanding of your mental health prior to the Treatment.

Profile Information

All information is kept private.

Beck's Depression Inventory

Questionnaires

Sadness

0 - I do not feel sad

1- I feel sad

2 - I am sad all the time and I can't snap out of it

3 - I am so sad and unhappy that I can't stand it

The Future

0 - I am not particularly discouraged about the future

1- I feel discouraged about the future

2 - I feel I have nothing to look forward to

3 - I feel the future is hopeless and that things cannot improve

Failure

0 - I do not feel like a failure

1- I feel I have failed more than the average person

2 - As I look back on my life, all I can see is a lot of failures

3 - I feel I am a complete failure as a person

Satisfaction

0 - I get as much satisfaction out of things as I used to

1- I don't enjoy things the way I used to

2 - I don't get real satisfaction out of anything anymore

3 - I am dissatisfied or bored with everything

Guilty

0 - I don't feel particularly guilty

1- I feel guilty a good part of the time

2 - I feel quite guilty most of the time

3 - I feel guilty all of the time

Punished

0 - I don't feel I am being punished

1- I feel I may be punished

2 - I expect to be punished

3 - I feel I am being punished

Disappointed

0 - I don't feel disappointed in myself

1- I am disappointed in myself

2 - I am disgusted with myself

3 - I hate myself

Feelings

0 - I don't feel I am any worse than anybody else

1- I am critical of myself for my weaknesses or mistakes

2 - I blame myself all the time for my faults

3 - I blame myself for everything bad that happens

Thoughts

0 - I don't have any thoughts of killing myself

1- I have thoughts of killing myself, but I would not carry them out

2 - I would like to kill myself

3 - I would kill myself if I had the chance

Crying

0 - I don't cry any more than usual

1- I cry more now than I used to

2 - I cry all the time now

3 - I used to be able to cry, but now I can't cry even though I want to

Irritation

0 - I am no more irritated by things than I ever was

1- I am slightly more irritated now than usual

2 - I am quite annoyed or irritated a good deal of the time

3 - I feel irritated all the time

Interests

0 - I have not lost interest in other people

1- I am less interested in other people than I used to be

2 - I have lost most of my interest in other people

3 - I have lost all of my interest in other people

Decision Making

0 - I make decisions about as well as I ever could.

1- I put off making decisions more than I used to

2 - I have greater difficulty in making decisions more than I used to

3 - I can't make decisions at all anymore

Appearance

0 - I don't feel that I look any worse than I used to

1- I am worried that I am looking old or unattractive

2 - I feel there are permanent changes in my appearance that make me look unattractive

3 - I believe that I look ugly

Motivation

0 - I can work about as well as before

1- It takes an extra effort to get started at doing something

2 - I have to push myself very hard to do anything

3 - I can't do any work at all

Sleep

0 - I can sleep as well as usual

1- I don't sleep as well as I used to

2 - I wake up 1-2 hours earlier than usual and find it hard to get back to sleep

3 - I wake up several hours earlier than I used to and cannot get back to sleep

Being Tired

0 - I don't get more tired than usual

1- I get tired more easily than I used to

2 - I get tired from doing almost anything

3 - I am too tired to do anything

Appetite

0 - My appetite is no worse than usual

1- My appetite is not as good as it used to be

2 - My appetite is much worse now

3 - I have no appetite at all anymore

Weight

0 - I haven't lost much weight, if any, lately

1- I have lost more than five pounds

2 - I have lost more than ten pounds

3 - I have lost more than fifteen pounds

Being Worried

0 -I am no more worried about my health than usual

1- I am worried about physical problems like aches, pains, upset stomach, or constipation

2 - I am very worried about physical problems and it's hard to think of much else

3 - I am so worried about my physical problems that I cannot think of anything else

Sex

0 - I have not noticed any recent change in my interest in sex

1- I am less interested in sex than I used to be

2 - I have almost no interest in sex

3 - I have lost interest in sex completely

Add up your total score 1-10 ups and downs are normal 11-16 mild mood disturbances 17-20 Borderline clinical depression 21-30 Moderate depression 31 -40 Severe Depression over 40 Extreme Depression.

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things

no days (0)

several days (1)

more than half (2)

nearly every day (3)

Feeling down, depressed, or hopeless

no days (0)

several days (1)

more than half (2)

nearly every day (3)

Trouble falling asleep/staying asleep/sleeping too much

no days (0)

several days (1)

more than half (2)

nearly every day (3)

Feeling tired, having little energy

no days (0)

several days (1)

more than half (2)

nearly every day (3)

Poor appetite or overeating

no days (0)

several days (1)

more than half (2)

nearly every day (3)

Feeling bad about yourself, or that you are a failure, or have let yourself or your family down

no days (0)

several days (1)

more than half (2)

nearly every day (3)

Trouble concentrating on things (reading, conversations, etc)

no days (0)

several days (1)

more than half (2)

nearly every day (3)

Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around more than usual.

no days (0)

several days (1)

more than half (2)

nearly every day (3)

Thoughts that you would be better off dead or of hurting yourself in some way

no days (0)

several days (1)

more than half (2)

nearly every day (3)

If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

no days (0)

several days (1)

more than half (2)

nearly every day (3)

Generalized Anxiety Disorder 7 item (GAD-7) Scale

Please answer Over the last 2 weeks how often have you been bothered by the following

Feeling nervous, anxious or on edge

0 - Not at all sure

1 - Several days

2 - Over half the days

3 - Nearly every day

Not being able to stop or control worrying

0 - Not at all sure

1 - Several days

2 - Over half the days

3 - Nearly every day

Worring too much about different things

0 - Not at all sure

1 - Several days

2 - Over half the days

3 - Nearly every day

Trouble relaxing

0 - Not at all sure

1 - Several days

2 - Over half the days

3 - Nearly every day

Being so restless that it is hard to sit still

0 - Not at all sure

1 - Several days

2 - Over half the days

3 - Nearly every day

Becoming easily annoyed or irriatable

0 - Not at all sure

1 - Several days

2 - Over half the days

3 - Nearly every day

Feeling afraid as if something awful might happen

0 - Not at all sure

1 - Several days

2 - Over half the days

3 - Nearly every day