History Questionnaire 1 Your Info2 Therapy History3 Anti-depressants4 Anti-psychotics5 Medical History Your InfoFirst Name*Last Name*Email* Phone*Date of Birth*Your Insurance ProviderPolicy NumberInsurance Policy NumberGroup NumberInsurance Group Number Therapy HistoryHave you tried TMS before?*YesNoPrevious Doctor*Hz*Date Began* Date Format: MM slash DD slash YYYY Date Ended* Date Format: MM slash DD slash YYYY If you don't know the exact dates an approximation is fine.Was it Successful*Are you currently in or have you ever tried talk therapy?*YesNoPrevious Therapist*Date Began* Date Format: MM slash DD slash YYYY Date Ended* Date Format: MM slash DD slash YYYY If you don't know the exact dates an approximation is fine.Was it Effective* Anti-DepressantsWhich SSRIs have you taken in the past?* Citalopram (Celexa) Escitalopram (Lexapro) Paroxetine (Paxil) Fluoxetine (Prozac) Fluvoxamine (Luvox) Sertraline (Zoloft) Other (Please Specify) I haven't Tried SSRIs Citalopram (Celexa)What Dosage of Citalopram (Celexa)When did you start taking Citalopram (Celexia)* Date Format: MM slash DD slash YYYY When did you stop taking Citalopram (Celexa)* Date Format: MM slash DD slash YYYY If you don't know the exact dates an approximation is fine.Did you experience any side effects from Citalopram (celexa)? If so what were they?Escitalopram (Lexapro)What Dosage of Escitalopram (Lexapro)*drug < 4 wks or 4 wks or more and dosage 1-9mg/day4 wks or more and dosage 10-19 mg/day4 wks or more and dosage 20-39 mg/day4 wks or more and dosage ≥ 40 mg/dayWhen did you start taking Escitalopram (Lexapro)* Date Format: MM slash DD slash YYYY When did you stop taking Escitalopram (Lexapro)* Date Format: MM slash DD slash YYYY If you don't know the exact date an approximation is fine.Did you experience any side effects from Escitalopram (Lexapro)? If so what were they?Paroxetine (Paxil)What Dosage of Paroxetine (Paxil)*drug < 4 wks or 4 wks or more and dosage <1-9mg/day4 wks or more and dosage 10-19 mg/day4 wks or more and dosage 20-29 mg/day4 wks or more and dosage ≥ 30 mg/dayWhen did you start taking Paroxetine (Paxil)* Date Format: MM slash DD slash YYYY When did you stop taking Paroxetine (Paxil)* Date Format: MM slash DD slash YYYY If you don't know the exact date an approximation is fine.Did you experience any side effects from Paroxetine (Paxil)? If so what were they?Fluoxetine (Prozac)What Dosage of Fluoxetine (Prozac)*drug < 4 wks or 4 wks or more and dosage 1-9mg/day4 wks or more and dosage 10-19 mg/day4 wks or more and dosage 20-39 mg/day4 wks or more and dosage ≥ 40 mg/dayWhen did you start taking Fluoxetine (Prozac)* Date Format: MM slash DD slash YYYY When did you stop taking Fluoxetine (Prozac)* Date Format: MM slash DD slash YYYY If you don't know the exact date an approximation is fine.Did you experience any side effects from Fluoxetine (Prozac)? If so what were they?Fluvoxamine (Luvox)What Dosage of Fluvoxamine (Luvox)*drug < 4 wks or drug < 100 mg/day4 wks or more and dosage 100-199 mg/day4 wks or more and dosage 200-299 mg/day4 wks or more and dosage 300 mg/day or greaterWhen did you start taking Fluvoxamine (Luvox)?* Date Format: MM slash DD slash YYYY When did you stop taking Fluvoxamine (Luvox)?* Date Format: MM slash DD slash YYYY If you don't know the exact date an approximation is fine.Did you experience any side effects from Fluvoxamine (Luvox)? If so what were they?Sertraline (Zoloft)What dosage of Sertraline (Zoloft)?*drug < 4 wks or drug < 100 mg/day4 wks or more and dosage 100-199 mg/day4 wks or more and dosage 200-299 mg/day4 wks or more and dosage 300 mg/day or greaterWhen did you start taking Sertraline (Zoloft)?* Date Format: MM slash DD slash YYYY When did you stop taking Sertraline (Zoloft)?* Date Format: MM slash DD slash YYYY If you don't know the exact date an approximation is fine.Did you experience any side effects from Sertraline (Zoloft)? If so what were they?Other SSRIs (Please Specify)Which other SSRIs have you tried? When did you start and stop taking them? Did you experience any side effects from them and If so what were they?**Other MedicationsWhich other medications have you taken in the past?* Vilazodone (Viibryd) Vortioxetine (Trintellix) Bupropion (Wellbutrin) Buspirone (Buspar) Lithium (Eskalith) Trazodone Mirtazapine (Zispin) Selegiline (Emsam) Adderall Spravato Other I haven't tried anti-depressants Vilazodone (Viibryd)What dosage of Vilazodone (Viibryd)?*When did you start taking Vilazodone (Viibryd)?* Date Format: MM slash DD slash YYYY When did you stop taking Vilazodone (Viibryd)?* Date Format: MM slash DD slash YYYY If you don't know the exact date an approximation is fine.Did you experience any side effects from Vilazodone (Viibryd)? If so what were they?Vortioxetine (Trintellix)What dosage of Vortioxetine (Trintellix)?*When did you start taking Vortioxetine (Trintellix)?* Date Format: MM slash DD slash YYYY When did you stop taking Vortioxetine (Trintellix)?* Date Format: MM slash DD slash YYYY If you don't know the exact date an approximation is fine.Did you experience any side effects from Vortioxetine (Trintellix)? If so what were they?Bupropion (Wellbutrin)What dosage of Bupropion (Wellbutrin)?*drug < 4 wks or 4 wks or more and dosage < 150 mg/day4 wks or more and dosage 150-299 mg/day4 wks or more and dosage 300-449 mg/day4 wks or more and dosage ≥ 450 mg/dayWhen did you start taking Bupropion (Wellbutrin)?* Date Format: MM slash DD slash YYYY When did you stop taking Bupropion (Wellbutrin)?* Date Format: MM slash DD slash YYYY If you don't know the exact dates an approximation is fine.Did you experience any side effects from Bupropion (Wellbutrin)? If so what were they?Buspirone (Buspar)What dosage of Buspirone (Buspar)?*When did you start taking Buspirone (Buspar)* Date Format: MM slash DD slash YYYY When did you stop taking Buspirone (Buspar)* Date Format: MM slash DD slash YYYY If you don't know the exact dates an approximation is fine.Did you experience any side effects from Buspirone (Buspar)? If so what were they?Lithium (Eskalith)What dosage of Lithium (Eskalith)?*drug <4 wks or 4 wks or more and level < 0.4 mEq/L4 wks or more and level 0.41-0.6 mEq/L4 wks or more and level > 0.6 mEq/LWhen did you start taking Lithium (Eskalith)* Date Format: MM slash DD slash YYYY When did you stop taking Lithium (Eskalith)* Date Format: MM slash DD slash YYYY If you don't know the exact dates an approximation is fine.Did you experience any side effects from Lithium (Eskalith)? If so what were they?TrazodoneWhat dosage of Trazodone?*drug < 4 wks or 4 wks or more and dosage < 200 mg/day4 wks or more and dosage 200-399 mg/day4 wks or more and dosage 400-599 mg/day4 wks or more and dosage ≥ 600 mg/dayWhen did you start taking Trazodone* Date Format: MM slash DD slash YYYY When did you stop taking Trazodone* Date Format: MM slash DD slash YYYY If you don't know the exact dates an approximation is fine.Did you experience any side effects from Trazodone? If so what were they?Mirtazapine (Zispin)What dosage of Mirtazapine (Zispin)?*drug < 4 wks or 4 wks or more and dosage < 15 mg/day4 wks or more and dosage 15-29 mg/day4 wks or more and dosage 30-44 mg/day4 wks or more and dosage ≥ 45 mg/dayWhen did you start taking Mirtazapine (Zispin)?* Date Format: MM slash DD slash YYYY When did you stop taking Mirtazapine (Zispin)?* Date Format: MM slash DD slash YYYY If you don't know the exact dates an approximation is fine.Did you experience any side effects from Mirtazapine (Zispin)? If so what were they?Selegiline (Emsam)What dosage of Selegiline (Emsam)?*drug < 4 wks or 4 wks or more and dosage < 20mg/day4 wks or more and dosage 21-40 mg/day4 wks or more and dosage 41-59 mg/day4 wks or more and dosage ≥ 60 mg/dayWhen did you start taking Selegiline (Emsam)?* Date Format: MM slash DD slash YYYY When did you stop taking Selegiline (Emsam)?* Date Format: MM slash DD slash YYYY If you don't know the exact dates an approximation is fine.Did you experience any side effects from Selegiline (Emsam)? If so what were they?AdderallWhat dosage of Adderall?*When did you start taking Adderall?* Date Format: MM slash DD slash YYYY When did you stop taking Adderall?* Date Format: MM slash DD slash YYYY If you don't know the exact dates an approximation is fine.Did you experience any side effects from Adderall? If so what were they?SpravatoWhat dosage of Spravato?*When did you start taking Spravato?* Date Format: MM slash DD slash YYYY When did you stop taking Spravato?* Date Format: MM slash DD slash YYYY If you don't know the exact dates an approximation is fine.Did you experience any side effects from Spravato? If so what were they?Other Anti-depressantsWhich other anti-depressants have you tried? When did you start and stop taking them? Did you experience any side effects from them and If so what were they?* AntipsychoticsWhich atypical antipsychotics have you taken in the past? Please include relevant dosages, medication duration, and any side-effects you may have experienced:* Lamictal (Lamotrigine) Lurasidone (Latuda) Quetiapine (Seroquel) Aripiprazole (Abilify) Brexpiprazole (Rexulti) Olanzapine (Zyprexa) Risperidone (Risperdal) None of the Above Lamictal (Lamotrigine)What dosage of Lamictal (Lamotrigine)?*drug < 4 wks or 4 wks or more dosage < 150 mg/day4 wks or more and dosage 150 – 299 mg/day4 wks or more and dosage ≥ 300 mg/dayWhen did you start taking Lamictal (Lamotrigine)?* Date Format: MM slash DD slash YYYY When did you stop taking Lamictal (Lamotrigine)?* Date Format: MM slash DD slash YYYY Did you experience any side-effects from Lamictal (Lamotrigine)? If so, what were they?Lurasidone (Latuda)What dosage of Lurasidone (Latuda)?*When did you start taking Lurasidone (Latuda)?* Date Format: MM slash DD slash YYYY When did you stop taking Lurasidone (Latuda)?* Date Format: MM slash DD slash YYYY Did you experience any side-effects from Lurasidone (Latuda)? If so, what were they?Quetiapine (Seroquel)What dosage of Quetiapine (Seroquel)?*When did you start taking Quetiapine (Seroquel)?* Date Format: MM slash DD slash YYYY When did you stop taking Quetiapine (Seroquel)?* Date Format: MM slash DD slash YYYY Did you experience any side-effects from Quetiapine (Seroquel)? If so, what were they?Aripiprazole (Abilify)What dosage of Aripiprazole (Abilify)?*When did you start taking Aripiprazole (Abilify)?* Date Format: MM slash DD slash YYYY When did you stop taking Aripiprazole (Abilify)?* Date Format: MM slash DD slash YYYY Did you experience any side-effects from Aripiprazole (Abilify)? If so, what were they?Brexpiprazole (Rexulti)What dosage of Brexpiprazole (Rexulti) did you take?*When did you start taking Brexpiprazole (Rexulti)?* Date Format: MM slash DD slash YYYY When did you start taking Brexpiprazole (Rexulti)?* Date Format: MM slash DD slash YYYY Did you experience any side-effects from Brexpiprazole (Rexulti)? If so, what were they?Olanzapine (Zyprexa)What dosage of Olanzapine (Zyprexa) did you take?*When did you start taking Olanzapine (Zyprexa)?* Date Format: MM slash DD slash YYYY When did you stop taking Olanzapine (Zyprexa)?* Date Format: MM slash DD slash YYYY Did you experience any side-effects from Olanzapine (Zyprexa)? If so, what were they?Risperidone (Risperdal)What dosage of Risperidone (Risperdal) did you take?*When did you start taking Risperidone (Risperdal)?* Date Format: MM slash DD slash YYYY When did you stop taking Risperidone (Risperdal)?* Date Format: MM slash DD slash YYYY Did you experience any side-effects from Risperidone (Risperdal)? If so, what were they? Medical HistoryMedical HistoryDo you have a history of any of the following:* Seizures Cerebrovascular disease Dementia Increased intracranial pressure Traumatic brain injury None of the above Do you have any of the following implants:* Cardioverter defibrillator Metal aneurysm clips, coils, staples, or stents Cochlear implants Vagus nerve stimulator Pacemaker None of the above About this formThis form is a preauthorization form forTMS, Spravato (Ketamine), or combination therapy. Please fill this out to expedite your treatment process.