TMS Candidate Screening Tool

   Transcranial Magnetic Stimulation Therapy (TMS) is a new breakthrough biologically-based, non-invasive, non-drug medical treatment option provided in an outpatient setting.
Happy People
Are you 18 years of age or over?
               Yes       No
Do you suffer from depression?
               Yes       No
Have you tried anti-depressant medications with unstatisfactory results?
               Yes       No
Are you interested in a treatment that could reduce or eliminate your depression symptoms without medications and virtually no side-effects?
Take this questionnaire to find out if TMS is right for you.
Answer the questions below as honestly as possible
Over the last 2 weeks, how often have you been bothered by any of the following problems?
(check the appropriate box to indicate your answer)
1.  Little interest or pleasure in doing things
0
1
2
3
2.  Feeling down, depressed, or hopeless
0
1
2
3
3.  Trouble falling or staying asleep, or sleeping too much
0
1
2
3
4.  Feeling tired or having little energy
0
1
2
3
5.  Poor appetite or overeating
0
1
2
3
6.  Feeling bad about yourself - or that you are a failure or have let yourself or your family down
0
1
2
3
7.  Trouble concentrating on things, such as reading the newspaper or watching television
0
1
2
3
8.  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 a lot more than usual
0
1
2
3
9.  Thoughts that you would be better off dead, or of hurting yourself
0
1
2
3
We will be happy to contact you about TMS. Please enter your name with a phone number and/or an email address where you can be reached.   You can also call 480-471-8560 and ask to talk to a TMS Specialist today.
Name:            Phone Number:
Email Address:
(to submit the form, something must be entered in all fields)

American Board of Psychiatry and Neurology    American Academy of Child & Adolescent Psychiatry    American Psychiatric Association