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TMS Assessment Form
Over the last 2 weeks, how often have you been bothered by any of the following problems?
(Select only one for each question)
1. Little interest or pleasure in doing things
Select one...
Not at all
Several days
More than half the days
Nearly every day
2. Feeling down, depressed, or hopeless
Select one...
Not at all
Several days
More than half the days
Nearly every day
3. Trouble falling or staying asleep, or sleeping too much
Select one...
Not at all
Several days
More than half the days
Nearly every day
4. Feeling tired or having little energy
Select one...
Not at all
Several days
More than half the days
Nearly every day
5. Poor appetite or overeating
Select one...
Not at all
Several days
More than half the days
Nearly every day
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Select one...
Not at all
Several days
More than half the days
Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television
Select one...
Not at all
Several days
More than half the days
Nearly every day
8. Moving or speaking so slowly that other people couldhave noticed? Or the opposite — being so fidgety orrestless that you have been moving around a lot more thanusual
Select one...
Not at all
Several days
More than half the days
Nearly every day
9. Thoughts that you would be better off dead or of hurting yourself in some way
Select one...
Not at all
Several days
More than half the days
Nearly every day
Additional Questions
(Select only one for each question)
10. 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?
Select one...
Not Difficult
Somewhat Difficult
Very Difficult
Extremely Difficult
11. How many anti-depressant medications have you tried including that you are currently using?
Select one...
1
2
3
4
More than 5
12. Who is your insurance provider?
Select one...
Medicare
Bluecross / Carefirst
Other Commercial
See Results
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Your Results
We're sorry, based on your results you don't qualify for TMS Therapy.
Your Results
You qualify for TMS Therapy!
Contact Psych Associates of Maryland for TMS Treatment Today
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