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TMS Education
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POST TX: Responder Status
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Identifies as: Male, Female, Non-Binary
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Referred By (Hopemark Provider)
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Protocol Referred For
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Past TMS Treatments
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Mapping Date & Time
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Mapping Location
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Insurance Carrier
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Other Novel Therapies
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May Require Addition Appointment Time
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Do you currently see a therapist? If so - name and location
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ROI Status - Share progress with a therapist
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Introduced Hopemark Therapy. Pt interested?
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If Interested - send to Therapy Department
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Were you referred by a mental health provider
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ROI for Outside Provider
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Forms Reviewed with Patient
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TMS Consent form Reviewed
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Patient Packet Reviewed
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Billing from in chart and reviewed
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Further info needed from billing
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Questions asked by patient
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Medications To Monitor
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Areas of Mental Health
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Impact of Depression /OCD
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Physical, Social, Nutrition ,Mind-body Info
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Employment
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Occupation
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Relationship Status
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Children
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Initial & End Scale Scores
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Beginning Scale Scores
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End Score
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Lifestyle
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Sleep - How many hours of sleep do you typically get?
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Sleep Issues
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Have you had a sleep study? If so When/Results
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Any interest in seeing our sleep specialist?
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Do you drink caffiene?
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Average Caffeine Intake
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Do you consume alcohol?
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Average Alcohol Intake
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Do you smoke, vape, or chew tobacco?
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If yes - how much and how often?
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Do you smoke, vape, or use THC gummies?
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Describe THC use - how often, how much?
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Any other substances?
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Describe other substances
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Headache, Neck or Back Pain
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Additional patient comments
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YBOC - Outline for Provocation
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Obsessions/Compulsions/Avoidance
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Patient Comments
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