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

2. Feeling down, depressed, or hopeless

3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down

7. Trouble concentrating on things, such as reading the newspaper or watching television

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

9. Thoughts that you would be better off dead or of hurting yourself in some way

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?

11. How many anti-depressant medications have you tried including that you are currently using?

12. Who is your insurance provider?

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