Mount Sinai Psychiatric Neuromodulation Prospective Patient Form

To be considered for transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), or deep brain stimulation (DBS) 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!

First and Last Name

* must provide value

Date of birth

* must provide value

M-D-Y

Age

View equation

Phone number

* must provide value

Address

* must provide value

Expand

E-mail

* must provide value

Additional Contact Information

Expand

Insurance Type/Carrier

* must provide value

Group number

* must provide value

ID number

* must provide value

Diagnosis

* must provide value

Main Symptoms

* must provide value

Symptom Onset (month/year)

* must provide value

Reason for Seeking an Evaluation

* must provide value

Which mental health clinician(s) are you currently seeing regularly?

* must provide value

Contact Information for Current or Most Recent Mental Health Clinician(s)

* must provide value

Past Medical and Surgical History

* must provide value

Expand

Current Medications, Dose and Duration

* must provide value

Expand

Medication or Other Allergies

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:

Interventions

Cognitive Behavioral Therapy (CBT)

Duration/dates or number of treatments:

* must provide value

Exposure and Response Prevention (ERP)

Duration/dates or number of treatments:

* must provide value

Interpersonal Therapy (IPT)

Duration/dates or number of treatments:

* must provide value

Other psychotherapies

Duration/dates or number of treatments:

* must provide value

Deep Brain Stimulation (DBS)

Duration/dates or number of treatments:

* must provide value

Vagus Nerve Stimulation (VNS)

Duration/dates or number of treatments:

* must provide value

Transcranial Magnetic Stimulation (TMS)

Duration/dates or number of treatments:

* must provide value

Transcranial Direct Current Stimulation (tDCS)

Duration/dates or number of treatments:

* must provide value

Electroconvulsive Therapy (ECT)

Duration/dates or number of treatments:

* must provide value

Please indicate if you have any of the following implants:

Cochlear implant

Deep brain stimulator

Vagus nerve stimulator

Implanted magnetic-sensitive medical device (eg. pacemaker)

Metallic hardware (eg. surgical implants)

Implant type:

Do you have a history of seizures or a neurologic disease that may influence seizure threshold?

* must provide value

Yes No

reset

Do you have a history of psychosis?

* must provide value

Yes No

reset

Please indicate any other relevant medications or interventions you have tried, along with their doses and durations here.

Expand

Thank you for referring to the Psychiatric Neuromodulation Program at Mount Sinai!

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.