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Perfect Balance Psychiatric Services and TMS Center
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Step 1

patient information
Insurance information/ Responsible Party Information
HEALTHCARE PROVIDERS

I authorize release of the results of my treatment upon conclusion to:

(Guardian’s Signature if Patient is under 18)

Step 2

HEALTH HISTORY QUESTIONAIRE

Before receiving TMS treatment we need to make sure it is safe for you to do so. We will need information about possible factors that could enhance your risk to unintentional adverse effects Please fill out the following questionnaire:

3. Do you have any of the following implants in your body?
If yes did any problems occur during scanning

SSRI’s (Fluoxetine, Paroxetine, Citalopram, Escitalopram, Sertraline, Fluvoxamine)

SNRI (Venlafaxine, Desvenlafaxine, Duloxetine, Fetzima)

Wellbutrin (Bupropion)

Step 3

7.In the past few years have you used any of the following substances:
Substances Used Age first started Use frequency Years Used Last use Current use Treatment
Cannabis/ Mj/ Weed
COCAINE
AMPHETAMINES/METH Other Stimulants
HEROIN or OTHER OPIOIDS- Pain pills
HALLUCINOGENS LSD, PCP, Mushrooms Ecstasy, Nitrous Oxide
Inhalants

ALL PATIENTS/RESPONSIBLE PARTIES PLEASE READ AND SIGN BELOW

By signing below, I attest I have answered all questions truthfully and t the best of my knowledge

(Guardian’s Signature if Patient is under 18)

Step 4

Ask the patient: how often have they been bothered by the following over the past 2 weeks?

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 could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?

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

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Points

Please make an appointment for this patient

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Effective Date of Notice: January 01, 22

This Notice of Privacy Practices applies to the following organizations.

Perfect Balance Psychiatric Services

I am a patient of Perfect Balance Psychiatric Services. I hereby acknowledge receipt of Perfect Balance Psychiatric Services’ Notice of Privacy Practices.

(Guardian’s Signature if Patient is under 18)