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rTMS Assessment for Treatment Resistant Depression
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Current Medication Regimen
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Has the patient been stable on medication regimen for at least 30 days?
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Medication Trials
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Dose Range/dates/Response/Side Effects/Ineffective
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Medication Trials
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Dose Range/Dates/Response/Side Effects/Ineffective
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Medication Trials
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Dose Range/Dates/Response/Side Effects/Ineffective
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Medication Trials
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Dose Range/Dates/Response/Side Effects/Ineffective
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Medication Trials
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Dose Range/Dates/Response/Side Effects/Ineffective
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Medication Trials
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Dose Range/Dates/Response/Side Effects/Ineffective
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Augmentation
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Dose Range/Dates/Response/Side Effects/Ineffective
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Augmentation
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Dose Range/Dates/Response/Side Effects/Ineffective
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Augmentation
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Dose Range/Date/Response/Side Effects/Ineffective
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Prior Treatment Modalities
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Has the patient had rTMS in the past?
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Dates of prior rTMS treatment
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Requested Treatment Plan
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Psychotherapy
• • •
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Treatment guidelines have been reviewed with patient.
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Does the patient have a history of seizures?
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History of brain mass or structural brain lesion, cerebral infarct, active CNS disease, or other neurologic abnormality
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Has the patient had brain surgery?
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Does the patient have a pacemaker or medication infusion device?
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Is the patient on medications that significantly lower seizure threshold?
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Has the patient sustained a TBI in the last 60 days
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Has the patient been abusing substance in the last 30 days?
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Does the patient have any implanted devices in the head?
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If the patient has a history of metal in their head, have they been cleared for rTMS?
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Is patient aware that ECT is a possible treatment option for their treatment resistant depression?
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Over the last 2 weeks, how often have you been bothered by
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1. Little interest or pleasure doing things
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2. Feeling down / depressed / hopeless
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3. Trouble falling or staying asleep, or sleeping too much
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4. Feeling tired and having little energy
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5. Poor appetite or over eating
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6. Feeling bad about yourself/feeling a failure/feeling you have let people down:
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7. Trouble concentrating on things, such as reading the newspaper/watching television
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8. Moving/Speaking so slow that other people could have noticed/the opposite
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9. Thoughts that you would be better off dead or of hurting yourself in someway
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PHQ 9 Score
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