The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

Working …

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Mount Sinai Psychiatric Neuromodulation Prospective Patient Form

To be considered for neuromodulation intake, please complete the survey below. After reviewing your completed form, our team will reach out to discuss your eligibility to continue the screening process. Please allow 1-2 weeks for review.

For additional questions, our team can be reached at neuromodulation.info@mssm.edu

Thank you!

Loading...

Thank you for reaching out to the Mount Sinai Psychiatric Neuromodulation Program.

This form helps our team understand your situation so we can work out how best to help.

Please be as detailed as you can and fill out as much of the form as you are able to. If you do not know an answer, you can skip it or say you are not sure.

Who sees your answers? What you write here goes to the Mount Sinai Psychiatric Neuromodulation team and is stored in REDCap, Mount Sinai's secure database for clinical and research information.

Who is filling in this form?

* must provide value

The patient

A family member or caregiver

A referring clinician or provider

Do you know the specifics of the treatments you have had before?

Yes

No

First name

* must provide value

Last name

* must provide value

Date of birth

* must provide value

M-D-Y

Age

View equation

Phone number

* must provide value

E-mail

* must provide value

Street address

* must provide value

Apartment, unit, or floor

City

* must provide value

State

* must provide value

ZIP code

* must provide value

Any other contact information we should have

Expand

Insurance carrier

* must provide value

Please tell us your insurance carrier

* must provide value

Group number

* must provide value

ID number

* must provide value

What is your primary condition you're seeking help for?

* must provide value

Please choose from the full list.

Please describe your primary condition.

How would you describe it at its current worst?

Mild Moderate Severe Not sure

What is the status of your condition?

Currently symptomatic

Partly improved

In remission, but I have had episodes before

Not sure

Have there ever been psychotic features, such as hallucinations or delusions?

Yes

No

Have symptoms continued despite adequate treatment with medication?

Yes, several treatments have not worked

Some treatments have helped partly

No

Not sure

Any other conditions you have been diagnosed with?

Agoraphobia

Alcohol Use Disorder

Alzheimer's Disease

Anorexia Nervosa

Antisocial Personality Disorder

Aphasia

Autism Spectrum Disorder

Avoidant Personality Disorder

Binge Eating Disorder

Bipolar I Disorder

Bipolar II Disorder

Borderline Personality Disorder

Brief Reactive Psychosis

Bulimia Nervosa

Chronic Fatigue Syndrome / ME

Dementia (major neurocognitive disorder)

Dependent Personality Disorder

Epilepsy

Fibromyalgia

Functional Movement Disorder

Functional Neurological Disorder

Functional Truncal Myoclonus Tremor

Generalized Anxiety Disorder

Histrionic Personality Disorder

Hyperacusis

Hypothyroidism

Insomnia

Intermittent Explosive Disorder

Learning Disorder (please specify)

Lennox-Gastaut Syndrome

Long COVID

Major Depressive Disorder

Mild Cognitive Impairment

Mood Disorder, not otherwise specified

Narcissistic Personality Disorder

Obsessive-Compulsive Disorder

Obsessive-Compulsive Personality Disorder

Panic Disorder

Paranoid Personality Disorder

Parkinson's Disease

Persistent Depressive Disorder (dysthymia)

Persistent Tic Disorder

Personality Disorder, not otherwise specified

Post-Traumatic Stress Disorder (Trauma)

Premenstrual Dysphoric Disorder (PMDD)

Psychosis, not otherwise specified

Schizoaffective Disorder

Schizoid Personality Disorder

Schizophrenia

Schizophreniform Disorder

Schizotypal Personality Disorder

Social Anxiety Disorder

Somatic Symptom Disorder

Specific Phobia

Substance Use Disorder

Tinnitus

Tourette's Syndrome

Traumatic Brain Injury

Treatment-Resistant Depression

Trichotillomania (hair-pulling)

Other (please specify)

Please tell us the other condition

Any other medical conditions we should know about?

Expand

What symptoms do you experience?

* must provide value

Expand

Roughly when did these symptoms begin? Month

* must provide value

Year

* must provide value

What are you hoping to be considered for?

* must provide value

Transcranial Magnetic Stimulation (TMS)

Vagus Nerve Stimulation (VNS)

Deep Brain Stimulation (DBS)

Electroconvulsive Therapy (ECT)

Ketamine or esketamine (Spravato)

Transcranial Electrical Stimulation (tDCS, tACS, tRNS)

I am not sure - I would like advice

Something else

What else are you hoping for?

Clinician 1: name

* must provide value

Clinician 1: role

Clinician 1: phone

* must provide value

Clinician 1: Email

* must provide value

Clinician 1: other contact details

Do you see another clinician regularly?

Yes

No

Clinician 2: name

Clinician 2: role

Clinician 2: phone

Clinician 2: Email

Clinician 2: other contact details

Do you see another clinician regularly?

Yes

No

Clinician 3: name

Clinician 3: role

Clinician 3: phone

Clinician 3: Email

Clinician 3: other contact details

Medication 1: name

Medication 1: dose

Medication 1: how long have you taken it?

Add another medication?

Yes

No

Medication 2: name

Medication 2: dose

Medication 2: how long have you taken it?

Add another medication?

Yes

No

Medication 3: name

Medication 3: dose

Medication 3: how long have you taken it?

Add another medication?

Yes

No

Medication 4: name

Medication 4: dose

Medication 4: how long have you taken it?

Add another medication?

Yes

No

Medication 5: name

Medication 5: dose

Medication 5: how long have you taken it?

Add another medication?

Yes

No

Medication 6: name

Medication 6: dose

Medication 6: how long have you taken it?

Add another medication?

Yes

No

Medication 7: name

Medication 7: dose

Medication 7: how long have you taken it?

Add another medication?

Yes

No

Medication 8: name

Medication 8: dose

Medication 8: how long have you taken it?

Anything else about your current medications?

Expand

Do you have any allergies to medications or otherwise?

* must provide value

Yes

No

Please tell us about your allergies:

* must provide value

Expand

SSRIs

Citalopram (Celexa)

Dose:
Taken minimum dose (20mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Escitalopram (Lexapro)

Dose:
Taken minimum dose (10mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Fluvoxamine (Luvox)

Dose:
Taken minimum dose (50mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Fluoxetine (Prozac)

Dose:
Taken minimum dose (20mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Sertraline (Zoloft)

Dose:
Taken minimum dose (50mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Paroxetine (Paxil, Pexeva)

Dose:
Taken minimum dose (20mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

SNRIs

Desvenlafaxine (Pristiq, Khedezla)

Dose:
Taken minimum dose (50mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Duloxetine (Cymbalta, Irenka)

Dose:
Taken minimum dose (60mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Levomilnacipran (Fetzima)

Dose:
Taken minimum dose (40mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Milnacipran (Savella)

Dose:
Taken minimum dose (100mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Venlafaxine (Effexor XR)

Dose:
Taken minimum dose (150mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Dose:
Taken minimum dose (40mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Atomoxetine (Strattera)

Tricyclics

Amitriptyline (Elavil)

Dose:
Taken minimum dose (150mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Desipramine (Norpramin)

Dose:
Taken minimum dose (150mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Clomipramine (Anafranil)

Dose:
Taken minimum dose (150mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Imipramine (Tofranil)

Dose:
Taken minimum dose (150mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Nortriptyline (Pamelor)

Dose:
Taken minimum dose (75mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Doxepin (Sinequan, Quitaxon, Aponal)

Dose:
Taken minimum dose (150mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Protriptyline (Vivactil)

Dose:
Taken minimum dose (30mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Trimipramine (Surmontil)

Dose:
Taken minimum dose (150mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

MAOIs

Rasagiline (Azilect)

Dose:
Taken minimum dose (0.5mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Selegiline (Eldepryl, Zelapar)

Dose:
Taken minimum dose (6mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Isocarboxazid (Marplan)

Dose:
Taken minimum dose (30mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Phenelzine (Nardil)

Dose:
Taken minimum dose (45mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Tranylcypromine (Parnate)

Dose:
Taken minimum dose (30mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Other antidepressants

Bupropion (Wellbutrin)

Dose:
Taken minimum dose (200mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Mirtazapine (Remeron)

Dose:
Taken minimum dose (15mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Deseryl (Trazodone)

Dose:
Taken minimum dose (150mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Serzone (Nefazodone)

Dose:
Taken minimum dose (300mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Trintellix/Brintellix (Vortioxetine)

Dose:
Taken minimum dose (10mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Valdoxan (Agomelatine)

Dose:
Taken minimum dose (25mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Edronax (Reboxetine)

Dose:
Taken minimum dose (4mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

* must provide value

Stablon (Tianeptine)

Dose:
Taken minimum dose (37.5mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Vilazodone (Viibryd)

Dose:
Taken minimum dose (20mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Lithium (Eskalith, Lithobid)

Dose:
Taken minimum dose (300mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

* must provide value

Amoxapine (Asendin)

Dose:
Taken minimum dose (150mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Thyroid Hormone Preparations

Dose:
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Buspar (Buspirone)

Dose:
Taken minimum dose (15mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Abilify (Aripiprazole)

Dose:
Taken minimum dose (2mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Seroquel (Quetiapine)

Dose:
Taken minimum dose (150mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Zyprexa (Olanzapine)

Dose:
Taken minimum dose (2.5mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Risperdal (Risperidone)

Dose:
Taken minimum dose (1mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Geodon (Ziprasidone)

Dose:
Taken minimum dose (20mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Latuda (Lurasidone)

Dose:
Taken minimum dose (40mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Saphris (Asenapine)

Dose:
Taken minimum dose (10mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Rexulti (Brexpiprazole)

Dose:
Taken minimum dose (0.5mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Vraylar (Cariprazine)

Dose:
Taken minimum dose (1.5mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Fanapt (Iloperidone)

Dose:
Taken minimum dose (2mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Invega (Paliperidone)

Dose:
Taken minimum dose (3mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Lamictal (Lamotrigine)

Dose:
Taken minimum dose (300mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Depakote (Divalproex)

Dose:
Taken minimum dose (750mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Carbamazepine (Carbatrol, Tegretol)

Dose:
Taken minimum dose (200mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Oxtellar (Oxcarbazepine)

Dose:
Taken minimum dose (600mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Clozapine (Clozaril, Fazaclo)

Dose:
Taken minimum dose (300mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Stimulant (Ritalin, Adderall, Vyvanse)

Dose:
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Other Medications

Clonidine (Catapres, Kapvay)

Dose:
Taken minimum dose (0.1mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Guanfacine (Tenex, Intuniv)

Dose:
Taken minimum dose (1mg/day) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Esketamine (Spravato)

Dose:
Taken minimum dose (56mg/dose) for at least four weeks?
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Ketamine IV

Dose:
Start date:
End date:
Medication outcome, side effects and/or reason for stopping:

Have you taken any of these medications more than once, at different times?

Expand

Treatments you have tried before

We ask about each one separately. If you have not had a treatment, answer no and the questions for it disappear. Try to be as detailed as possible; approximate dates are fine.

If you have had the same treatment more than once with a break in between, we will ask about each course on its own.

Have you ever had Electroconvulsive Therapy (ECT)?

Yes

No

Approximately when did it start?

M-D-Y

When did it finish?

M-D-Y

Roughly how many sessions or treatments?

What kind of ECT?

Acute course

Continuation or maintenance

Magnetic Seizure Therapy (MST)

FEAST

Not sure

Electrode placement

Right unilateral (RUL)

Bifrontal (BF)

Bitemporal (BT)

Bilateral

Not sure

Waveform

Sine wave (SW)

Brief pulse (BP)

Ultrabrief pulse (UBP)

Not sure

Dose relative to seizure threshold (%)

Absolute dose

How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

Please describe the outcome

Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

Please tell us why it stopped

Have you had a separate course of this since then?

Yes

No

(Second course) Approximately when did it start?

M-D-Y

(Second course) When did it finish?

M-D-Y

(Second course) Roughly how many sessions or treatments?

(Second course) What kind of ECT?

Acute course

Continuation or maintenance

Magnetic Seizure Therapy (MST)

FEAST

Not sure

(Second course) Electrode placement

Right unilateral (RUL)

Bifrontal (BF)

Bitemporal (BT)

Bilateral

Not sure

(Second course) Waveform

Sine wave (SW)

Brief pulse (BP)

Ultrabrief pulse (UBP)

Not sure

(Second course) Dose relative to seizure threshold (%)

(Second course) Absolute dose

(Second course) How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

(Second course) Please describe the outcome

(Second course) Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

(Second course) Please tell us why it stopped

Was there a third separate course?

Yes

No

(Third course) Approximately when did it start?

M-D-Y

(Third course) When did it finish?

M-D-Y

(Third course) Roughly how many sessions or treatments?

(Third course) What kind of ECT?

Acute course

Continuation or maintenance

Magnetic Seizure Therapy (MST)

FEAST

Not sure

(Third course) Electrode placement

Right unilateral (RUL)

Bifrontal (BF)

Bitemporal (BT)

Bilateral

Not sure

(Third course) Waveform

Sine wave (SW)

Brief pulse (BP)

Ultrabrief pulse (UBP)

Not sure

(Third course) Dose relative to seizure threshold (%)

(Third course) Absolute dose

(Third course) How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

(Third course) Please describe the outcome

(Third course) Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

(Third course) Please tell us why it stopped

Have you ever had Transcranial Magnetic Stimulation (TMS)?

Yes

No

Approximately when did it start?

M-D-Y

When did it finish?

M-D-Y

Roughly how many sessions or treatments?

Which side?

Left

Right

Both sides

Not sure

Target area

Dorsolateral prefrontal cortex (dlPFC)

Medial frontal cortex (MFC)

Not sure

Other

Which target?

Pulse frequency and protocol

Standard high frequency (10 Hz)

Low frequency (1 Hz)

Intermittent theta burst (iTBS)

Stanford Neuromodulation Therapy (SNT, accelerated iTBS)

Not sure

Other

Device or coil, if known

Pulses per session

Dose relative to motor threshold (%)

Sessions per day

How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

Please describe the outcome

Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

Please tell us why it stopped

Have you had a separate course of this since then?

Yes

No

(Second course) Approximately when did it start?

M-D-Y

(Second course) When did it finish?

M-D-Y

(Second course) Roughly how many sessions or treatments?

(Second course) Which side?

Left

Right

Both sides

Not sure

(Second course) Target area

Dorsolateral prefrontal cortex (dlPFC)

Medial frontal cortex (MFC)

Not sure

Other

(Second course) Which target?

(Second course) Pulse frequency and protocol

Standard high frequency (10 Hz)

Low frequency (1 Hz)

Intermittent theta burst (iTBS)

Stanford Neuromodulation Therapy (SNT, accelerated iTBS)

Not sure

Other

(Second course) Device or coil, if known

(Second course) Pulses per session

(Second course) Dose relative to motor threshold (%)

(Second course) Sessions per day

(Second course) How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

(Second course) Please describe the outcome

(Second course) Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

(Second course) Please tell us why it stopped

Was there a third separate course?

Yes

No

(Third course) Approximately when did it start?

M-D-Y

(Third course) When did it finish?

M-D-Y

(Third course) Roughly how many sessions or treatments?

(Third course) Which side?

Left

Right

Both sides

Not sure

(Third course) Target area

Dorsolateral prefrontal cortex (dlPFC)

Medial frontal cortex (MFC)

Not sure

Other

(Third course) Which target?

(Third course) Pulse frequency and protocol

Standard high frequency (10 Hz)

Low frequency (1 Hz)

Intermittent theta burst (iTBS)

Stanford Neuromodulation Therapy (SNT, accelerated iTBS)

Not sure

Other

(Third course) Device or coil, if known

(Third course) Pulses per session

(Third course) Dose relative to motor threshold (%)

(Third course) Sessions per day

(Third course) How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

(Third course) Please describe the outcome

(Third course) Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

(Third course) Please tell us why it stopped

Have you ever underwent Vagus Nerve Stimulation and/or had a VNS device implanted?

Yes

No

Approximately when did it start?

M-D-Y

If discontinued, when?

M-D-Y

Roughly how many sessions or treatments?

Current (mA)

Pulse width (µs, microseconds)

Frequency (Hz)

Duty cycle (seconds on per minute)

How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

Please describe the outcome

Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

Please tell us why it stopped

Have you had a separate course of this since or an additional VNS implant procedure then?

Yes

No

(Second course) Approximately when did it start?

M-D-Y

(Second course) When did it finish?

M-D-Y

(Second course) Roughly how many sessions or treatments?

(Second course) Current (mA)

(Second course) Pulse width (µs, microseconds)

(Second course) Frequency (Hz)

(Second course) Duty cycle (seconds on per minute)

(Second course) How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

(Second course) Please describe the outcome

(Second course) Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

(Second course) Please tell us why it stopped

Was there a third separate course or implant?

Yes

No

(Third course) Approximately when did it start?

M-D-Y

(Third course) And when did it finish?

M-D-Y

(Third course) Roughly how many sessions or treatments?

(Third course) Current (mA)

(Third course) Pulse width (µs, microseconds)

(Third course) Frequency (Hz)

(Third course) Duty cycle (seconds on per minute)

(Third course) How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

(Third course) Please describe the outcome

(Third course) Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

(Third course) Please tell us why it stopped

Have you ever had Deep Brain Stimulation (DBS)?

Yes

No

Approximately when did it start/when were you implanted?

M-D-Y

If completed/explanted, when?

M-D-Y

Which brain target?

Current (mA)

Pulse width (µs, microseconds)

Frequency (Hz)

How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

Please describe the outcome

Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

Please tell us why it stopped

Have you had a separate course/implant?

Yes

No

(Second course) Approximately when did it start?

M-D-Y

(Second course) When did it finish/when were you explanted, if at all?

M-D-Y

(Second course) Which brain target?

(Second course) Current (mA)

(Second course) Pulse width (µs, microseconds)

(Second course) Frequency (Hz)

(Second course) How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

(Second course) Please describe the outcome

(Second course) Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

(Second course) Please tell us why it stopped

Have you ever had Transcranial Electrical Stimulation (tDCS, tACS or tRNS)?

Yes

No

Approximately when did it start?

M-D-Y

And when did it finish?

M-D-Y

Roughly how many sessions or treatments?

Which type?

Transcranial direct current stimulation (tDCS)

Transcranial alternating current stimulation (tACS)

Transcranial random noise stimulation (tRNS)

Not sure

How long was each session (minutes)?

Anode location

Cathode location

Electrical dose (mA)

How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

Please describe the outcome

Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

Please tell us why it stopped

Have you had a separate course of this since then?

Yes

No

(Second course) Approximately when did it start?

M-D-Y

(Second course) And when did it finish?

M-D-Y

(Second course) Roughly how many sessions or treatments?

(Second course) Which type?

Transcranial direct current stimulation (tDCS)

Transcranial alternating current stimulation (tACS)

Transcranial random noise stimulation (tRNS)

Not sure

(Second course) How long was each session (minutes)?

(Second course) Anode location

(Second course) Cathode location

(Second course) Electrical dose (mA)

(Second course) How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

(Second course) Please describe the outcome

(Second course) Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

(Second course) Please tell us why it stopped

And a third separate course after that?

Yes

No

(Third course) Approximately when did it start?

M-D-Y

(Third course) And when did it finish?

M-D-Y

(Third course) Roughly how many sessions or treatments?

(Third course) Which type?

Transcranial direct current stimulation (tDCS)

Transcranial alternating current stimulation (tACS)

Transcranial random noise stimulation (tRNS)

Not sure

(Third course) How long was each session (minutes)?

(Third course) Anode location

(Third course) Cathode location

(Third course) Electrical dose (mA)

(Third course) How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

(Third course) Please describe the outcome

(Third course) Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

(Third course) Please tell us why it stopped

Have you ever had Light therapy?

Yes

No

Approximately when did it start?

M-D-Y

And when did it finish?

M-D-Y

Roughly how many sessions or treatments?

What kind of light box?

How long was each session (minutes)?

Light color

White

Blue

Green

Not sure

Other

Which color?

Light intensity (lux)

How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

Please describe the outcome

Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

Please tell us why it stopped

Have you had a separate course of this since then?

Yes

No

(Second course) Approximately when did it start?

M-D-Y

(Second course) And when did it finish?

M-D-Y

(Second course) Roughly how many sessions or treatments?

(Second course) What kind of light box?

(Second course) How long was each session (minutes)?

(Second course) Light color

White

Blue

Green

Not sure

Other

(Second course) Which color?

(Second course) Light intensity (lux)

(Second course) How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

(Second course) Please describe the outcome

(Second course) Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

(Second course) Please tell us why it stopped

And a third separate course after that?

Yes

No

(Third course) Approximately when did it start?

M-D-Y

(Third course) And when did it finish?

M-D-Y

(Third course) Roughly how many sessions or treatments?

(Third course) What kind of light box?

(Third course) How long was each session (minutes)?

(Third course) Light color

White

Blue

Green

Not sure

Other

(Third course) Which color?

(Third course) Light intensity (lux)

(Third course) How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

(Third course) Please describe the outcome

(Third course) Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

(Third course) Please tell us why it stopped

Have you ever had psychotherapy or counselling?

Yes

No

Which kinds?

Acceptance and Commitment Therapy (ACT)

Behavioral Therapy (BT)

Cognitive Behavioral Therapy (CBT)

Interpersonal Therapy (IPT)

Problem-Solving Therapy (PST)

Short-Term Psychodynamic Psychotherapy (STPP)

Dialectical Behavior Therapy (DBT)

Exposure and Response Prevention (ERP)

Not sure what it was called

Other

Which other kind?

Approximately when did it start?

M-D-Y

And when did it finish?

M-D-Y

Duration in weeks

View equation

In what format?

Individual Couple Family Group Other

Which format?

Roughly how many sessions?

How often?

More than once a week

Weekly

Every two weeks

Monthly

Less often

Not sure

How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

Please describe the outcome

Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

Please tell us why it stopped

Have you had a separate course of this since then?

Yes

No

(Second course) Which kinds?

Acceptance and Commitment Therapy (ACT)

Behavioral Therapy (BT)

Cognitive Behavioral Therapy (CBT)

Interpersonal Therapy (IPT)

Problem-Solving Therapy (PST)

Short-Term Psychodynamic Psychotherapy (STPP)

Dialectical Behavior Therapy (DBT)

Exposure and Response Prevention (ERP)

Not sure what it was called

Other

(Second course) Which other kind?

(Second course) Approximately when did it start?

M-D-Y

(Second course) And when did it finish?

M-D-Y

(Second course) Duration in weeks

View equation

(Second course) In what format?

Individual Couple Family Group Other

(Second course) Which format?

(Second course) Roughly how many sessions?

(Second course) How often?

More than once a week

Weekly

Every two weeks

Monthly

Less often

Not sure

(Second course) How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

(Second course) Please describe the outcome

(Second course) Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

(Second course) Please tell us why it stopped

And a third separate course after that?

Yes

No

(Third course) Which kinds?

Acceptance and Commitment Therapy (ACT)

Behavioral Therapy (BT)

Cognitive Behavioral Therapy (CBT)

Interpersonal Therapy (IPT)

Problem-Solving Therapy (PST)

Short-Term Psychodynamic Psychotherapy (STPP)

Dialectical Behavior Therapy (DBT)

Exposure and Response Prevention (ERP)

Not sure what it was called

Other

(Third course) Which other kind?

(Third course) Approximately when did it start?

M-D-Y

(Third course) And when did it finish?

M-D-Y

(Third course) Duration in weeks

View equation

(Third course) In what format?

Individual Couple Family Group Other

(Third course) Which format?

(Third course) Roughly how many sessions?

(Third course) How often?

More than once a week

Weekly

Every two weeks

Monthly

Less often

Not sure

(Third course) How did it go?

Very much improved

Much improved

A little improved

No change

A little worse

Much worse

Very much worse

It helped, but the benefit did not last

Not sure

Other

(Third course) Please describe the outcome

(Third course) Why did it stop?

It did not help enough

Side effects, or I could not tolerate it

My own preference

Cost

It worked well enough that we stopped

I am still having it

Not sure

Other

(Third course) Please tell us why it stopped

Additional Questions

Do you have any of the following implants?

* must provide value

Cochlear implant

Deep brain stimulator

Vagus nerve stimulator

Implanted magnetic-sensitive device, such as a pacemaker

Metallic hardware, such as surgical implants

Something else

None of these

Please tell us about the implant

* must provide value

Do you have a history of seizures, or a neurological condition that could affect seizure threshold?

* must provide value

Yes

No

Please describe your seizure history in your own words

* must provide value

Expand

Do you have a history of psychosis?

* must provide value

Yes

No

Anything you would like to add about that?

Expand

Any other treatments or medications you have tried that we have not asked about?

Expand

Is there anything else you would like us to know?

Expand

Thank you very much for your interest in Mount Sinai Neuromodulation!

Mark field as:

[Clear value]

No information, No information (NI)

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.