TMS Assessment - Is TMS Therapy right for me?
Do you have epilepsy or have you ever had a convulsion or a seizure?
Yes
No
Have you ever had a fainting spell or syncope? If yes, please describe on which occasion(s)?
Yes
No
Have you ever had a head trauma that was diagnosed as a concussion or was associated with loss of consciousness?
Yes
No
Do you have any hearing problems or ringing in your ears?
Yes
No
Do you suffer from frequent headaches?
Yes
No
Do you have cochlear implants?
Yes
No
Are you pregnant or is there any chance that you might be?
Yes
No
Do you have metal in the brain, skull or elsewhere in your body (e.g., splinters, fragments, clips, etc.)? If so, specify the type of metal.
Yes
No
Do you have an implanted neurostimulator (e.g., DBS, epidural/subdural, VNS)?
Yes
No
Did you ever undergo TMS in the past? If so, were there any problems?
Yes
No
Did you ever undergo MRI in the past? If so, were there any problems?
Yes
No
How soon are you looking to take care of your depression?
As soon as possible
This week
This month
Within the next 3 months
Have you ever been diagnosed with Treatment-Resistant Depression or Major Depressive Disorder (MDD)?
*
Yes
No
Have you had suicidal thoughts in the past year?
Yes
No
How many antidepressant medications have you tried?
*
0-1
2-4
4 or more
Have you ever been diagnosed with Bipolar, Schizophrenia, or other psychotic illnesses?
Yes, Bipolar
Yes, Schizophrenia
Yes, other
Yes, but I may have been misdiagnosed
No
Have you tried therapy, counseling, or coaching?
Yes, it has helped me
Yes, I have tried with insufficient benefits
Yes, but I stopped going because it wasn't working and/or I didn't like it
No, I have never tried it
Have you heard about TMS Therapy before?
Yes
No
Where have you heard about TMS Therapy?
Evolve Health
Facebook / Instagram
Google
Television
Friend/Family
Other
I have not heard of TMS
Who are you taking this survey for?
Myself
Spouse/Partner
Sibling
Parent
Friend
Have you abused any of the following substances in the past 12 months?
Alcohol
Narcotics
Marijuana
Hallucinogens
Prescription Medication
Tobacco / Nicotine
More than one of these
None of these
Do you currently use any other recreational drugs other than Marijuana?
Yes, frequently
Yes, occasionally
No, I used to but I stopped
No, I have never tried any
What is your gender?
Male
Female
Non-binary
Other
Rather not say
Do you have health insurance?
Yes
No
Which insurance do you have?
*
United Healthcare
Regence
Blue Cross Blue Shield (BCBS)
Aetna
Cigna
Pacific Source
Moda
Kaiser Permanente
Providence
Medicare
Medicaid
OHP
VA
Other
None
What is your age?
Under 18
18-24
25-49
50-64
65 or older
First Name (Please press ENTER after entering your information)
*
Last Name (Please press ENTER after entering your information)
*
Phone (Please press ENTER after entering your information)
*
Email (Please press ENTER after entering your information)
*
Which TMS location?
*
Portland, OR
Beaverton, OR
