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5560 Sterrett Place, Suite 201, Columbia, MD 21044
Phone:
(443) 546-1100
Fax: (443) 546-4005
Is TMS Right For You?
Are you taking medication to treat your depression?
Yes
No
Are you still depressed despite taking medication?
Yes
No
Have you switched medications more than once due to side effects?
Yes
No
Are depression symptoms interfering with your leisure activites, your relationships with your family and friends or your ability to work?
Yes
No
Name
Email
Phone
Over the past two weeks, how often have the following problems bothered you? Please answer to the best of your ability.
1. Little interest or pleasure in doing things
Not at all
2-3 days a week
4-6 days a week
Nearly everyday
2. Feeling down, depressed, or hopeless
Not at all
2-3 days a week
4-6 days a week
Nearly everyday
3. Trouble falling or staying asleep, or sleeping too much
Not at all
2-3 days a week
4-6 days a week
Nearly everyday
4. Feeling tired or having little energy
Not at all
2-3 days a week
4-6 days a week
Nearly everyday
5. Poor appetite or overeating
Not at all
2-3 days a week
4-6 days a week
Nearly everyday
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Not at all
2-3 days a week
4-6 days a week
Nearly everyday
7. Trouble concentrating on things, such as reading the newspaper or watching television
Not at all
2-3 days a week
4-6 days a week
Nearly everyday
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
Not at all
2-3 days a week
4-6 days a week
Nearly everyday
If you checked off any problems, 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
Not difficult at all
Somewhat difficult
Very difficult
Extremely Difficult
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