PHI Release - mind.md

Step 1 of 5 - Your Info

Your Info

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Date of Birth(Required)

Your Insurance Provider

Policy Number

Insurance Policy Number

Group Number

Insurance Group Number

Therapy History

Have you tried TMS before?(Required)

Yes

Previous Doctor(Required)

Hz(Required)

Date Began(Required)

MM slash DD slash YYYY

Date Ended(Required)

MM slash DD slash YYYY

If you don't know the exact dates an approximation is fine.

Was it Successful(Required)

Are you currently in or have you ever tried talk therapy?(Required)

Yes

Previous Therapist(Required)

Date Began(Required)

MM slash DD slash YYYY

Date Ended(Required)

MM slash DD slash YYYY

If you don't know the exact dates an approximation is fine.

Was it Effective(Required)

Anti-Depressants

Which SSRIs have you taken in the past?(Required)

Citalopram (Celexa)

Escitalopram (Lexapro)

Paroxetine (Paxil)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Sertraline (Zoloft)

Other (Please Specify)

I haven't Tried SSRIs

Citalopram (Celexa)

What Dosage of Citalopram (Celexa)

When did you start taking Citalopram (Celexia)(Required)

MM slash DD slash YYYY

When did you stop taking Citalopram (Celexa)(Required)

MM slash DD slash YYYY

If you don't know the exact dates an approximation is fine.

Did you experience any side effects from Citalopram (celexa)? If so what were they?

Escitalopram (Lexapro)

What Dosage of Escitalopram (Lexapro)(Required)

drug < 4 wks or 4 wks or more and dosage 1-9mg/day

4 wks or more and dosage 10-19 mg/day

4 wks or more and dosage 20-39 mg/day

4 wks or more and dosage ≥ 40 mg/day

When did you start taking Escitalopram (Lexapro)(Required)

MM slash DD slash YYYY

When did you stop taking Escitalopram (Lexapro)(Required)

MM slash DD slash YYYY

If you don't know the exact date an approximation is fine.

Did you experience any side effects from Escitalopram (Lexapro)? If so what were they?

Paroxetine (Paxil)

What Dosage of Paroxetine (Paxil)(Required)

drug < 4 wks or 4 wks or more and dosage <1-9mg/day

4 wks or more and dosage 10-19 mg/day

4 wks or more and dosage 20-29 mg/day

4 wks or more and dosage ≥ 30 mg/day

When did you start taking Paroxetine (Paxil)(Required)

MM slash DD slash YYYY

When did you stop taking Paroxetine (Paxil)(Required)

MM slash DD slash YYYY

If you don't know the exact date an approximation is fine.

Did you experience any side effects from Paroxetine (Paxil)? If so what were they?

Fluoxetine (Prozac)

What Dosage of Fluoxetine (Prozac)(Required)

drug < 4 wks or 4 wks or more and dosage 1-9mg/day

4 wks or more and dosage 10-19 mg/day

4 wks or more and dosage 20-39 mg/day

4 wks or more and dosage ≥ 40 mg/day

When did you start taking Fluoxetine (Prozac)(Required)

MM slash DD slash YYYY

When did you stop taking Fluoxetine (Prozac)(Required)

MM slash DD slash YYYY

If you don't know the exact date an approximation is fine.

Did you experience any side effects from Fluoxetine (Prozac)? If so what were they?

Fluvoxamine (Luvox)

What Dosage of Fluvoxamine (Luvox)(Required)

drug < 4 wks or drug < 100 mg/day

4 wks or more and dosage 100-199 mg/day

4 wks or more and dosage 200-299 mg/day

4 wks or more and dosage 300 mg/day or greater

When did you start taking Fluvoxamine (Luvox)?(Required)

MM slash DD slash YYYY

When did you stop taking Fluvoxamine (Luvox)?(Required)

MM slash DD slash YYYY

If you don't know the exact date an approximation is fine.

Did you experience any side effects from Fluvoxamine (Luvox)? If so what were they?

Sertraline (Zoloft)

What dosage of Sertraline (Zoloft)?(Required)

drug < 4 wks or drug < 100 mg/day

4 wks or more and dosage 100-199 mg/day

4 wks or more and dosage 200-299 mg/day

4 wks or more and dosage 300 mg/day or greater

When did you start taking Sertraline (Zoloft)?(Required)

MM slash DD slash YYYY

When did you stop taking Sertraline (Zoloft)?(Required)

MM slash DD slash YYYY

If you don't know the exact date an approximation is fine.

Did you experience any side effects from Sertraline (Zoloft)? If so what were they?

Other SSRIs (Please Specify)

Which other SSRIs have you tried? When did you start and stop taking them? Did you experience any side effects from them and If so what were they?*(Required)

Other Medications

Which other medications have you taken in the past?(Required)

Vilazodone (Viibryd)

Vortioxetine (Trintellix)

Bupropion (Wellbutrin)

Buspirone (Buspar)

Lithium (Eskalith)

Trazodone

Mirtazapine (Zispin)

Selegiline (Emsam)

Adderall

Spravato

Other

I haven't tried anti-depressants

Vilazodone (Viibryd)

What dosage of Vilazodone (Viibryd)?(Required)

When did you start taking Vilazodone (Viibryd)?(Required)

MM slash DD slash YYYY

When did you stop taking Vilazodone (Viibryd)?(Required)

MM slash DD slash YYYY

If you don't know the exact date an approximation is fine.

Did you experience any side effects from Vilazodone (Viibryd)? If so what were they?

Vortioxetine (Trintellix)

What dosage of Vortioxetine (Trintellix)?(Required)

When did you start taking Vortioxetine (Trintellix)?(Required)

MM slash DD slash YYYY

When did you stop taking Vortioxetine (Trintellix)?(Required)

MM slash DD slash YYYY

If you don't know the exact date an approximation is fine.

Did you experience any side effects from Vortioxetine (Trintellix)? If so what were they?

Bupropion (Wellbutrin)

What dosage of Bupropion (Wellbutrin)?(Required)

drug < 4 wks or 4 wks or more and dosage < 150 mg/day

4 wks or more and dosage 150-299 mg/day

4 wks or more and dosage 300-449 mg/day

4 wks or more and dosage ≥ 450 mg/day

When did you start taking Bupropion (Wellbutrin)?(Required)

MM slash DD slash YYYY

When did you stop taking Bupropion (Wellbutrin)?(Required)

MM slash DD slash YYYY

If you don't know the exact dates an approximation is fine.

Did you experience any side effects from Bupropion (Wellbutrin)? If so what were they?

Buspirone (Buspar)

What dosage of Buspirone (Buspar)?(Required)

When did you start taking Buspirone (Buspar)(Required)

MM slash DD slash YYYY

When did you stop taking Buspirone (Buspar)(Required)

MM slash DD slash YYYY

If you don't know the exact dates an approximation is fine.

Did you experience any side effects from Buspirone (Buspar)? If so what were they?

Lithium (Eskalith)

What dosage of Lithium (Eskalith)?(Required)

drug <4 wks or 4 wks or more and level < 0.4 mEq/L

4 wks or more and level 0.41-0.6 mEq/L

4 wks or more and level > 0.6 mEq/L

When did you start taking Lithium (Eskalith)(Required)

MM slash DD slash YYYY

When did you stop taking Lithium (Eskalith)(Required)

MM slash DD slash YYYY

If you don't know the exact dates an approximation is fine.

Did you experience any side effects from Lithium (Eskalith)? If so what were they?

Trazodone

What dosage of Trazodone?(Required)

drug < 4 wks or 4 wks or more and dosage < 200 mg/day

4 wks or more and dosage 200-399 mg/day

4 wks or more and dosage 400-599 mg/day

4 wks or more and dosage ≥ 600 mg/day

When did you start taking Trazodone(Required)

MM slash DD slash YYYY

When did you stop taking Trazodone(Required)

MM slash DD slash YYYY

If you don't know the exact dates an approximation is fine.

Did you experience any side effects from Trazodone? If so what were they?

Mirtazapine (Zispin)

What dosage of Mirtazapine (Zispin)?(Required)

drug < 4 wks or 4 wks or more and dosage < 15 mg/day

4 wks or more and dosage 15-29 mg/day

4 wks or more and dosage 30-44 mg/day

4 wks or more and dosage ≥ 45 mg/day

When did you start taking Mirtazapine (Zispin)?(Required)

MM slash DD slash YYYY

When did you stop taking Mirtazapine (Zispin)?(Required)

MM slash DD slash YYYY

If you don't know the exact dates an approximation is fine.

Did you experience any side effects from Mirtazapine (Zispin)? If so what were they?

Selegiline (Emsam)

What dosage of Selegiline (Emsam)?(Required)

drug < 4 wks or 4 wks or more and dosage < 20mg/day

4 wks or more and dosage 21-40 mg/day

4 wks or more and dosage 41-59 mg/day

4 wks or more and dosage ≥ 60 mg/day

When did you start taking Selegiline (Emsam)?(Required)

MM slash DD slash YYYY

When did you stop taking Selegiline (Emsam)?(Required)

MM slash DD slash YYYY

If you don't know the exact dates an approximation is fine.

Did you experience any side effects from Selegiline (Emsam)? If so what were they?

Adderall

What dosage of Adderall?(Required)

When did you start taking Adderall?(Required)

MM slash DD slash YYYY

When did you stop taking Adderall?(Required)

MM slash DD slash YYYY

If you don't know the exact dates an approximation is fine.

Did you experience any side effects from Adderall? If so what were they?

Spravato

What dosage of Spravato?(Required)

When did you start taking Spravato?(Required)

MM slash DD slash YYYY

When did you stop taking Spravato?(Required)

MM slash DD slash YYYY

If you don't know the exact dates an approximation is fine.

Did you experience any side effects from Spravato? If so what were they?

Other Anti-depressants

Which other anti-depressants have you tried? When did you start and stop taking them? Did you experience any side effects from them and If so what were they?*

Antipsychotics

Which atypical antipsychotics have you taken in the past? Please include relevant dosages, medication duration, and any side-effects you may have experienced:(Required)

Lamictal (Lamotrigine)

Lurasidone (Latuda)

Quetiapine (Seroquel)

Aripiprazole (Abilify)

Brexpiprazole (Rexulti)

Olanzapine (Zyprexa)

Risperidone (Risperdal)

None of the Above

Lamictal (Lamotrigine)

What dosage of Lamictal (Lamotrigine)?(Required)

drug < 4 wks or 4 wks or more dosage < 150 mg/day

4 wks or more and dosage 150 – 299 mg/day

4 wks or more and dosage ≥ 300 mg/day

When did you start taking Lamictal (Lamotrigine)?(Required)

MM slash DD slash YYYY

When did you stop taking Lamictal (Lamotrigine)?(Required)

MM slash DD slash YYYY

Did you experience any side-effects from Lamictal (Lamotrigine)? If so, what were they?

Lurasidone (Latuda)

What dosage of Lurasidone (Latuda)?(Required)

When did you start taking Lurasidone (Latuda)?(Required)

MM slash DD slash YYYY

When did you stop taking Lurasidone (Latuda)?(Required)

MM slash DD slash YYYY

Did you experience any side-effects from Lurasidone (Latuda)? If so, what were they?

Quetiapine (Seroquel)

What dosage of Quetiapine (Seroquel)?(Required)

When did you start taking Quetiapine (Seroquel)?(Required)

MM slash DD slash YYYY

When did you stop taking Quetiapine (Seroquel)?(Required)

MM slash DD slash YYYY

Did you experience any side-effects from Quetiapine (Seroquel)? If so, what were they?

Aripiprazole (Abilify)

What dosage of Aripiprazole (Abilify)?(Required)

When did you start taking Aripiprazole (Abilify)?(Required)

MM slash DD slash YYYY

When did you stop taking Aripiprazole (Abilify)?(Required)

MM slash DD slash YYYY

Did you experience any side-effects from Aripiprazole (Abilify)? If so, what were they?

Brexpiprazole (Rexulti)

What dosage of Brexpiprazole (Rexulti) did you take?(Required)

When did you start taking Brexpiprazole (Rexulti)?(Required)

MM slash DD slash YYYY

When did you start taking Brexpiprazole (Rexulti)?(Required)

MM slash DD slash YYYY

Did you experience any side-effects from Brexpiprazole (Rexulti)? If so, what were they?

Olanzapine (Zyprexa)

What dosage of Olanzapine (Zyprexa) did you take?(Required)

When did you start taking Olanzapine (Zyprexa)?(Required)

MM slash DD slash YYYY

When did you stop taking Olanzapine (Zyprexa)?(Required)

MM slash DD slash YYYY

Did you experience any side-effects from Olanzapine (Zyprexa)? If so, what were they?

Risperidone (Risperdal)

What dosage of Risperidone (Risperdal) did you take?(Required)

When did you start taking Risperidone (Risperdal)?(Required)

MM slash DD slash YYYY

When did you stop taking Risperidone (Risperdal)?(Required)

MM slash DD slash YYYY

Did you experience any side-effects from Risperidone (Risperdal)? If so, what were they?

Medical History

Do you have a history of any of the following:(Required)

Seizures

Cerebrovascular disease

Dementia

Increased intracranial pressure

Traumatic brain injury

None of the above

Do you have any of the following implants:(Required)

Cardioverter defibrillator

Metal aneurysm clips, coils, staples, or stents

Cochlear implants

Vagus nerve stimulator

Pacemaker

None of the above

Get a Consultation Online With Telemed

(847) 945-6463

Medical Release Form

Your Info

Therapy History

Anti-Depressants

Citalopram (Celexa)

Escitalopram (Lexapro)

Paroxetine (Paxil)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Sertraline (Zoloft)

Other SSRIs (Please Specify)

Other Medications

Vilazodone (Viibryd)

Vortioxetine (Trintellix)

Bupropion (Wellbutrin)

Buspirone (Buspar)

Lithium (Eskalith)

Trazodone

Mirtazapine (Zispin)

Selegiline (Emsam)

Adderall

Spravato

Other Anti-depressants

Antipsychotics

Lamictal (Lamotrigine)

Lurasidone (Latuda)

Quetiapine (Seroquel)

Aripiprazole (Abilify)

Brexpiprazole (Rexulti)

Olanzapine (Zyprexa)

Risperidone (Risperdal)

Medical History

Medical History

Company

Open hours