Repetitive Transcranial Magnetic Stimulation (rTMS) Referral Form

Patient Full Name *

Patient Phone Number *

Patient DOB *

Patient is currently an: *

InpatientOutpatient

This form is for internal use only

Patient Status: *

pt is a current Inpatient - rTMS later admission/Outpatient - assessment onlypt is a current Inpatient - rTMS this admission - rTMS admin team to advise if there is roompt is an outpatient - rTMS during an admissionpt is an outpatient - outpatient rTMS

Date of Admission *

Patients Current Inpatient Group *

MAPERACTMDAODPTSD1PTSD2No Group

PTSD REQUIRES PSYCHOMETRIC SCORING AND WILL BE CONFIRMED WITH PSYCHOLOGY FIRST

Current Medications *

Failed Medications *

Medicare Eligibility *

At least 18 years of ageBeen diagnosed with Major Depressive DisorderUnsatisfactory improvement following the trial of at least 2 different classes of antidepressant medicationUndertaken psychological therapyFirst time rTMS recipient

Safety Screen *

EpilepsyAny past seizureNeurologic IllnessHead/Eye Injury/SurgeryConcussionFainting or SyncopeRetinal Tear or DetachmentPast ECT/TMSCurrently Pregnant?Metal pins/PlatesHx of Psychosis or CatatonicRecent MRIRecent Medication ChangesNerve DamagePast Surgery: Write in comments sectionOther: Write in comments section

Presenting Problem *

DepressionAnxiety Adjustment Disorder Trauma- AdultTrauma - Childhood AddictionOther: Write in the comments section

Degree of impairment: *

LowModerateElevatedExtreme

Degree of suffering: *

LowModerateElevatedExtreme

Frequency of distress: *

LowModerateElevatedExtreme

Tendency to resort to alcohol/sedatives: *

LowModerateElevatedExtreme

Imminent suicide risk: *

LowModerateElevatedExtreme

Comments/Other Reasons; please provide details

Dr Name *

Dr Signature *

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Date of Referral *

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