Patient Name:
Date of Birth:
Clinician Name:
Is the patient 18 years of age or older? Please ChooseYesNo
Does the patient have a confirmed diagnosis of Major Depressive Disorder (MDD), moderate to severe, single or recurrent episode? Please ChooseYesNo
Has the diagnosis been confirmed by a psychiatrist? Please ChooseYesNo
Has the patient tried at least two antidepressants from two different classes? Please ChooseYesNo
If yes, were these medications used 6–8 weeks at a maximally tolerated or adequate dose? Please ChooseYesNo
Has the patient completed evidence-based psychotherapy during the current episode without significant improvement? Please ChooseYesNo
Has a validated depression scale been administered (PHQ-9, BDI, HAM-D, MADRS)? Please ChooseYesNo
Does the patient have untreated bipolar disorder, current or recent mania, or psychotic symptoms? Please ChooseYesNo
Does the patient have metal implants or ferromagnetic objects in or near the head? Please ChooseYesNo
Does the patient have a history of seizures or epilepsy? Please ChooseYesNo
Is the patient currently using benzodiazepines, alcohol, or other substances that may lower seizure threshold? Please ChooseYesNo
Does the patient have neurological conditions (stroke, TBI, brain tumor) requiring evaluation before TMS? Please ChooseYesNo
Is the patient pregnant or trying to become pregnant? Please ChooseYesNo
Does the patient have implanted medical devices (pacemakers, VNS, medication pumps)? Please ChooseYesNo
Has the patient ever received TMS treatment in the past? Please ChooseYesNo
If yes, provide relevant details (year, provider, outcome):
Can the patient commit to weekday treatments for 4–6 weeks? Please ChooseYesNo
Is the patient able to sit upright for 20–30 minutes per session? Please ChooseYesNo
Does the patient have insurance likely to cover TMS (Medicare, Medicaid, Optum, CareFirst, Aetna, Cigna, etc.)? Please ChooseYesNo
Is a clinical review needed? Please ChooseYesNo
