Inital TMS Clinical History Form
- Pioneer Health

Please answer the questions included on this form to your best of your ability. While we appreciate you answering all questions included on this form, you may leave sections blank if you would not like to answer.

This online form is secure and encrypted by Snap forms. It is stored securely according to Australian privacy legislation and all data is encrypted. This information will only be accessible by your psychiatrist.

Our Team will review all the answer you provide, and use your to answers to assist with the interview process during your initial appointment.

Thank you.

Patient Details

First Name *

Last Name *

Age (in years) *

Gender

Preferred Pronoun

Mobile Number:

Email Address

Employment

Occupation

Relationship status

Children

Name of GP (General Practitioner)

Name of GP clinic

TMS Clinic

Which Clinic do you want to go? *Choose a clinic closest to home or work which is convenient for you to travel to you appointment.

Past Medical History

If you ticked any of the above, please provide further details

How long have you had your condition for?

What are your current symptoms?

Do you have any other previous medical conditions not listed above? If so for how many years or months have you had this condition for?

Past Family History

Which family member had the MENTAL HEALTH condition?

Which family member had the NEUROLOGICAL condition?

Has your family members had any other health condition?

Psychiatric Presenting Symptoms and History

Please describe the symptoms you have been experiencing? What has been happening recently, that has led you to see a psychiatrist's review? *

Please confirm if you have had Depression?

Approximately what year were you diagnosed with Depression?

Have you ever been hospitalised for Depression

Are you currently in a depressive episode?

Please select your current symptoms of Depression?

Please confirm if you have had Bipolar?

Approximately what year were you diagnosed with Bipolar?

Have you ever been hospitalised for Bipolar?

Are you currently in a manic or depressive episode? ie. within the last few months

Please select your current symptoms of mania?

NILpressured/increased amount of speechracing thoughtsvery little sleep for consecutive daysgrandiose beliefs uncharacteristic risky or impulsive behaviours eg. spending large amounts of money

Please confirm if you have had Generalised Anxiety Disorder?

Approximately what year were you diagnosed with Generalised Anxiety Disorder?

Are you currently experiencing generalised anxiety symptoms? ie. within the last few months

Please confirm if you have had OCD?

Approximately what year were you diagnosed with OCD?

Have you ever been hospitalised for OCD?

Are you currently experiencing OCD symptoms? ie. within the last few months

Please confirm if you have had Post Traumatic Stress Disorder?

Approximately what year were you diagnosed with Post Traumatic Stress Disorder?

Have you ever been hospitalised for Post Traumatic Stress Disorder?

Are you currently experiencing Post Traumatic Stress Disorder symptoms? ie. within the last few months

Please select your current symptoms of Post Traumatic Stress Disorder?

NILnightmares related to the original traumaflashbacks related to the original traumaavoidance of anything that could remind you of the original traumahypervigilance (jumpy and on edge)decreased emotional expression

Please confirm if you have had Schizophrenia?

Approximately what year were you diagnosed with Schizophrenia?

Have you ever been hospitalised for Schizophrenia?

Are you currently experiencing symptoms of Schizophrenia? ie. within the last few months

Please select your current symptoms of Schizophrenia?

NILvoices (auditory hallucinations)visual hallucinationstactile hallucinations

Please confirm if you have had Borderline Personality Disorder?

Approximately what year were you diagnosed with Borderline Personality Disorder?

Have you ever been hospitalised for Borderline Personality Disorder?

Please select your current symptoms of Borderline Personality Disorder?

NILemotional dysregulationinability to tolerate rejection in romantic and non romantic relationshipsa tendency towards conflict in romantic and non romantic relationshipschronic emptinessimpulsivityanger management/rage

PAST HOSPITILISATIONS: Have you had any hospitalisations for mental health reasons. If so, please provide furthe detail eg. reason for admission, voluntary status, length of admission

Disclaimer

We will now be asking questions about your past medication history. We apologise for the level of detail we are requesting. For patients to be eligible for the Medicare rebate (with respect to depression), we do need this information. If you are unsure, please estimate to the best of your ability. We understand that some of this information can be very difficult to remember.

For full disclosure, we have included the criteria that need to be met in order to be eligible for the Medicare Rebate.

As per the Medicare rules, you are eligible for rTMS treatment if the following criteria is met:

You are over the age of 18 years
You have been diagnosed with a currentMajor Depressive Episode
You have tried and failed 2 or more antidepressant medications in the time period since your current Major Depressive Episode began (unless considered inappropriate by your treating doctor)
You have undertaken psychological therapy (unless considered inappropriate by your treating doctor)
You have not received rTMS treatment previously

Please note:

1. If you have a depression and another condition, please talk to our friendly admin team to find out if it is possible for us to treat both conditions during the same session.

2. The above has been paraphased from the Medicare website in order to enhance clarity. Please see this website for the original version. http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/419674E7069172A9CA25877800803903/$File/Factsheet-rTMS-Patient.25.10.21.pdf

In the interest of full disclosure, please be informed that Pax TMS is co-owned by Dr. Jonathon Laugharne and Dr. Shanek Wick. Please also note that your TMS referral is not limited to our clinic. You have the freedom to use it at any TMS service across Australia.

In the interest of full disclosure, please be informed that Neuralia TMS Palmyra and Nedlands is owned by Dr. Shanek Wick. Please also note that your TMS referral is not limited to our clinic. You have the freedom to use it at any TMS service across Australia.

In the interest of full disclosure, please be informed that Pioneer Health TMS is co-owned by Dr. David Tadj and Dr. Shanek Wick. Please also note that your TMS referral is not limited to our clinic. You have the freedom to use it at any TMS service across Australia.

In the interest of full disclosure, please be informed that Helena Valley TMS is co-owned by Dr Shane Head and Dr. Shanek Wick. Please also note that your TMS referral is not limited to our clinic. You have the freedom to use it at any TMS service across Australia.

In the interest of full disclosure, please be informed that Cortical TMS is co-owned by Dr. Cathrin Kusuma and Dr. Shanek Wick. Please also note that your TMS referral is not limited to our clinic. You have the freedom to use it at any TMS service across Australia.

Duration

When did your current episode begin? *In otherwords, when did you last feel persistently well or back at your usual baseline?

Medication

Have you ever taken an Antidepressant before? *

Current Antidepressant

Name of Current Antidepressant *

Current Dose (in mg):if not exactly known, please estimate to your best ability

Frequency *

Approximately how long ago did you commence this antidepressant? *if not exactly known, please estimate to your best ability

How long have you taken it for? *if not exactly known, please estimate to your best ability

Please see below for a list of all maximum doses as per the Australian Medical Handbook. Please note, it is not uncommon for psychiatrists to dose above these doses. Such practice is considered reasonable as psychiatrists have completed specialist training:

Escitalopram (Lexapro), max dose is 20mg

Citalopram (Cipramil), max dose is 40mg

Sertraline (Zoloft), max dose is 200mg

Fluoxetine (Prozac)m max dose is 60mg

Paroxetine (Paxil), max dose is 40mg

Fluvoxamine (Luvox), max dose is 300mg

Venlafaxine (Effexor), max dose is 150mg

Desvenlafaxine (Pristiq), max dose is 200mg

Duloxetine (Cymbalta), max dose is 120mg

Agomelatine (Valdoxan), max dose is 50mg

Vortioxetine (Brintillex), max dose is 20mg

Amitryptyline (Endep), max dose is 150mg

Nortryptyline, max dose is 150mg

Clomipramine (Anafranil), max dose is 150mg

Phenelzine, max dose is 90mg

Tranylcypromine, max dose is 60mg

Previous Antidepressant 1

Previous Antidepressant 1 *

What was the highest dose you reach (in mg)if not exactly known, please estimate to your best ability

Reason for stopping *

Approximately how long ago did you commence this antidepressant? *if not exactly known, please estimate to your best ability

How long have you taken it for? *if not exactly known, please estimate to your best ability

Escitalopram (Lexapro), max dose is 20mg

Citalopram (Cipramil), max dose is 40mg

Sertraline (Zoloft), max dose is 200mg

Fluoxetine (Prozac)m max dose is 60mg

Paroxetine (Paxil), max dose is 40mg

Fluvoxamine (Luvox), max dose is 300mg

Venlafaxine (Effexor), max dose is 150mg

Desvenlafaxine (Pristiq), max dose is 200mg

Duloxetine (Cymbalta), max dose is 120mg

Agomelatine (Valdoxan), max dose is 50mg

Vortioxetine (Brintillex), max dose is 20mg

Amitryptyline (Endep), max dose is 150mg

Nortryptyline, max dose is 150mg

Clomipramine (Anafranil), max dose is 150mg

Phenelzine, max dose is 90mg

Tranylcypromine, max dose is 60mg

Previous Antidepressant 2

Previous Antidepressant 2 *

Highest dose reached (please estimate if not known)if not exactly known, please estimate to your best ability

Reason for stopping

Approximately how long ago did you commence this antidepressant? *if not exactly known, please estimate to your best ability

How long have you taken it for? *if not exactly known, please estimate to your best ability

Escitalopram (Lexapro), max dose is 20mg

Citalopram (Cipramil), max dose is 40mg

Sertraline (Zoloft), max dose is 200mg

Fluoxetine (Prozac)m max dose is 60mg

Paroxetine (Paxil), max dose is 40mg

Fluvoxamine (Luvox), max dose is 300mg

Venlafaxine (Effexor), max dose is 150mg

Desvenlafaxine (Pristiq), max dose is 200mg

Duloxetine (Cymbalta), max dose is 120mg

Agomelatine (Valdoxan), max dose is 50mg

Vortioxetine (Brintillex), max dose is 20mg

Amitryptyline (Endep), max dose is 150mg

Nortryptyline, max dose is 150mg

Clomipramine (Anafranil), max dose is 150mg

Phenelzine, max dose is 90mg

Tranylcypromine, max dose is 60mg

Other Antidepressants:

Please provide details if you selected "Other" in any of the above questions

Other Psychiatric Medication

Other Current Medication

Please list the name, dose and frequency of any other medication you are currently taking *Please type "none" if you are not taking any other current medication

Psychological Treatments

Choose which of the following you have seen? *

PsychologistTherapistCouncellorNone

What type of psychological therapy have you tried? *

Name of your most recent Psychologist?

How long have you been seeing them for?

Neurostimulation

Have you ever previously tried TMS? *

YesNo

Allergies

Do you have any allergies to medication?

Please list any medication allergies you have had. What what was the reaction?

Alcohol

Do you drink alcohol? *

What type of alcohol do you generally drink? *

How much do you drink on average during a session? *

How often do you drink?

Have you experienced any of the following?

NoAlcohol Withdrawal Symptoms (tremors, palpitations)Seizures related to alcohol use

Recreational Drugs

Have you used any recreational drugs in the last 5 years? *

What type of recreational drugs have you used in the lat 5 years?

How often do you use drugs?

Have you experienced any of the following?

NoDrugs Withdrawal Symptoms (tremors, palpitations)Seizures related to benzodiazepine or other drug use

Smoking

Do you smoke cigarettes?

How many cigarettes do you smoke a day?

TMS

Please click here to read the consent form, if you have been referred for a suitability assessment for TMS (Transcranial Magnetic Stimulation). Your psychiatrist will then engage in a face-to-face discussion with you, covering the essential elements of this consent and explaining its implications. After this, you will have the opportunity to ask any questions you may have before signing the TMS consent form.

TMS is a drug-free, medicare subsidised and evidence-based treatment for Depression, OCD, PTSD and Chronic pain (including fibromyalgia). If you would like to learn more about this treatment, please visit our website our contact our friendly staff.

Declaration

I declare that the above information is correct. I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health care and treatment given to me.

Full name: *

Please sign here: *

Draw signature|Type signatureClear

Date:

Save and Complete Later