Deep Brain Stimulation (DBS) for Treatment-Refractory ...



Treatment Resistant Depression Clinic Services SummaryYour face-to-face evaluation at Emory you will be with Jocelyn Wise, LCSW and Dr. William McDonald, the director of the Treatment Resistant Depression Clinic. They may want you to be evaluated by others too, such as our psychologist.Following the evaluation, your case may be discussed with a group of Emory psychiatrists, psychologists, nurses, skilled therapists, and social workers. Together, we will formulate comprehensive recommendations.Treatment recommendations may include additional tests, changes in psychiatric medications, investigational treatments like Ketamine or Transcranial Magnetic Stimulation, types of talk therapy, substance abuse treatment, electroconvulsive therapy, and more. Treatment recommendations will be discussed with you over the phone. They will also be written up and sent to the psychiatrist who referred you. Follow-up treatment may need to be found outside of Emory Our coordinator will be getting in touch with you by phone 1 month, 2 months, and 3 months after your visit to see how you are doing.I have read the above summary of services and have an understanding of the services I may receive as part of my evaluation by the Treatment Resistant Depression Clinic. ________________________________________________________________Signature of Patient/Legal RepresentativeDate________________________________________________________________Printed NameDescription of Authority to Act for PatientAre you interested in being contacted about research studies in depression and other mood disorders? If so, do you give permission for us to give your number to a research coordinator to contact you about studies you may qualify for?YESNO Please check the kinds of studies of mental health you might be interested in learning more about (please check all that apply):_____Clinical studies of new medications or medication combinations in the treatment of mental illness (such as nervousness, anxiety, and depression)_____ Studies of the causes of mental illness (such as genetic studies, brain imaging studies, hormone studies, etc.)_____Clinical studies of non-medication treatments for mental illness (such as transcranial magnetic stimulation [TMS] or deep brain stimulation [DBS])_____Other: ___________________________________________________________PLEASE FILL OUT THE REMAINING PAGES AS COMPLETELY AS POSSIBLE AND SUBMIT THIS PACKET TO OUR CARE COORDINATOR IN ORDER TO OBTAIN AN APPOINTMENT. PLEASE FAX TO 404 712 7436.THANK YOU!Emory HealthcareTreatment-Resistant Depression Clinic Evaluation/Consultation New Patient Information FormName: _______________________________________________________________ Today’s date: __________________ Date of birth: __________________ Age: _____Telephone: _________________________ Alt telephone: ______________________ Best time(s) to call: _____________________ O.K. to leave a voice message? ______Email address: _________________________________________________________Mailing address:____________________________________________________________________________________________________________________________________________Primary outpatient psychiatrist: _____________________________________________Telephone: ________________________________ Fax: ______________________ Mailing address:____________________________________________________________________________________________________________________________________________History of Present IllnessPlease describe what problem(s) you would like us to help you with. When did this problem current begin? What kinds of things make the problem better or worse? What treatment have you previously received?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Review of Common SymptomsFor the following symptoms, please indicate whether you are currently experiencing this, experienced this in the past, or never experienced this. When did this occur?CurrentPastSymptomDepression, persistent sadness or feeling blueLoss of pleasure in activitiesDecreased motivationCrying spellsLack of energy or fatigueLoss of appetiteDifficulty falling asleepWaking up multiple times during the nightAwake early and cannot return to sleepIncreased sleepNot eating or weight loss without trying to lose weightDifficulty concentratingMemory problemsAnxious or restlessIrritable moodFeelings of guilt or worthlessnessLow self-esteemFeelings of hopelessnessAggressive/combative behaviorPanic or anxiety attacksAnxiety about social situations (such as speaking in public)Trouble with self-care (such as dressing or bathing)Racing thoughtsTalking more than usualIncreased activity (such as writing, cleaning, or exercising more)Increased risk-taking behaviorObsessive thoughts (symmetry, cleanliness, intrusive thoughts)Intrusive thoughts about something bad that happened to youCompulsive behaviors (counting, washing hands, cleaning)Paranoia (suspiciousness)Reading other people’s thoughtsFeeling that your thoughts are being readFeeling like the television or radio is talking to you specificallySeeing or hearing something that others can’tNot eating in order to lose weightExercising to lose weightUsing laxatives to lose weightUsing other methods to lose weight: ___________________________Overeating without feeling hungryBinging (eating large amounts)TraumaHave you ever experienced or witnessed a traumatic event? Traumatic events may include exposure to war, threatened or actual physical or sexual violence, natural or human-made disasters, and severe motor vehicle accidents. If so, please describe when and the nature of the event:__________________________________________________________________________________________________________________________________________________________________________________________________________________Current MedicationsPlease list all current medications including vitamins and over-the-counter/herbal products. Please include the dose of the medication and when you take it during the day.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Prior treatmentsPlease indicate the treatments you have tried for this problem, when you tried this and what the outcome was (it worked, didn’t work and/or you had side effects).TreatmentWhenWhereHow many sessionsOutcome Did it help?Y/N ordo not knowElectroconvulsive Therapy (ECT)Right unilateralECT BifrontalECT BitemporalTranscranial Magnetic Stimulation (rTMS)Transcranial Direct-Current Stimulation (tDCS)Vagal Nerve Stimulation (VNS)Ketamine InfusionsPast Medical HistoryFor the following medical conditions, please indicate whether this is a current problem, a past problem, or never a problem. When was this a problem?CurrentPastNeverMedical ConditionHigh blood pressureHeart diseaseBreathing problems (such as asthma or COPD)DiabetesCancer: _________________________________________________Thyroid problems (hypo- or hyperthyroidism)Acid refluxHigh cholesterolSleep apneaSeizuresStrokeTremorAbnormal movementsFaintingEye problems: ____________________________________________Chronic pain (such as back pain or other joint pain): ______________Anemia or other blood disorderChronic infectious disease (such as herpes, HIV, hepatitis): ________Other:Past Surgical HistoryPlease describe any surgical procedure you have had and what it was for:____________________________________________________________________________________________________________________________________________Allergies/Adverse Drug ReactionsPlease describe any drug, food or other allergies:____________________________________________________________________________________________________________________________________________Review of Common Physical SymptomsPlease indicate whether you have any of the following symptoms AT THIS TIME.SymptomCURRENTLY EXPERIENCINGFatigue or feeling ill (malaise)Weight loss or gainFever or chillsSweatingSwollen or painful lymph nodesCoughWheezingCoughing or spitting up bloodChest pain at restChest pain with activityPalpitations, heart pounding or heart racingSwollen anklesShortness of breath at restShortness of breath with activityDizziness of faintingHeadaches or migrainesFrequent fallsBalance problemsDifficulty walkingTremorNumbness or tingling in fingers or toesChange in handwritingSnoringForgetfulness or other memory problemsFeeling confusedChange in speech or voiceChange in ability to smellChange in ability to hearChange in ability to tasteChange in ability to seeEye painBlurred or double visionDifficulty swallowingHeartburn or acid refluxStomach or intestinal pain before or after eatingStomach or intestinal pain at restFeeling of heaviness or fullness in abdomenConstipationDiarrheaNausea or vomitingVomiting bloodBloody stools or blood in stoolVery dark or “tar-like” stoolsDifficulty getting or maintaining an erectionPremature ejaculationProlonged erection without ejaculationPain with intercourseDecreased libidoProblems with urination (painful or slow)Urinating frequentlyUrinary incontinence (difficulty holding your urine)Increased thirstDry mouth or eyesUnable to tolerate heat or coldChanges in color or texture of hairHair lossIncreased hair growthChange in height, head size, hand size or shoe sizeMuscle, bone or joint pain or stiffnessDifficulty standing from a sitting positionExcessive bleeding or easy bruisingRecurrent infections or difficulty recovering from infectionsDry skinOther skin changesRashNew moles or change in existing molesLumps under skinOther symptoms:Instructions: Please check the names of any medications that you have taken for at least 6 weeks since the beginning of THIS EPISODE or period of depression. Drug ClassGeneric NameYear drug was triedHighest Dose# Weeks drug was takenWas it helpful (Y/N)?Did you experience side effects?Did you stop due to side effects (Y/N)?SSRILuvoxFluvoxaminePaxilParoxetineProzacFluoxetineZoloftSertralineCelexaCitalopramLexaproEscitalopramSNRIEffexorVenlafaxineCymbaltaDuloxetinePristiqDesvenlafaxineSavellaMilnacipramFetzimaLevomilnacipramAnticonvulsantLithiumTegretolcarbamazepineDepakoteDivalproexNeurontinGabapentinLamictalLamotigineTrileptalOxacarbazepineDepakotevalproateDepakenevalproic acidAntipsychoticsAbilifyAripiprazoleSaphrisAsenapineClozarilClozapineFanaptIloperidoneLatudaLurasidoneZyprexaOlanzapineInvegaPaliperidoneSeroquelQuetiapineRisperdalRisperidoneGeodonZiprasidoneDrug ClassGeneric NameYear drug was triedHighest Dose# Weeks drug was takenWas it helpful (Y/N)?Did you experience side effects?Did you stop due to side effects (Y/N)?Sedatives and Sleeping AgentsKlonopinClonazepamXanaxAlprazolamValiumDiazepamBenadrylDiphenhydramineLunestaEszopicloneAtivanLorazepamSeraxOxazepamRestorilTemazepamTrazodoneHaliconTriazolamSonataZaleplonAmbienZolpidemAugmentingBusparBuspironeCytomelLioothyronineOmeha 3 FAStimulantsNuvigilArmodafinilAdderalamphetamineVyvanaseLisdexamphetamineRitalinMethylphenidateProvigilModafinilOtherStratteraAtomaxetineWellbutrinBupropionRemeronMirtazapineSerozoneNefazodoneEdronaxReboxatineStablonTianeptineVibrydVilazodoneBrintellixVortioxetineTCAAdapinDoxepinAnafranilClomipramineAsendinAmoxapineEndep/ElavilAmitriptylineLudiomilMaprotilineNorpraminDesipraminePamelorNortyrptilineDrug ClassGeneric NameYear drug was triedHighest Dose# Weeks drug was takenWas it helpful (Y/N)?Did you experience side effects?Did you stop due to side effects (Y/N)?SinequinDoxepinSurmontilTrimipramineTofranilImipramineVivactilProtryptilineAzafenPipofezineAgedal/EltronoNoxiptilineMerival/AlivalNomifensineMAOIsMarplanIsocarboxazidNardilPhenelzineParnateTranylcypromineEmsamSelegiline patchAurorixMoclobemidePirazidolPirlindoneSubstancesFor each of the substances below, please indicate how often you use/have used it.SubstanceUsed in pastUse currentlyHow much?How many times per week?AlcoholNicotineCaffeineCocaineMarijuanaHeroinOther opiatesBarbituratesBenzodiazepines (e.g., Valium)AmphetaminesHallucinogens (e.g., LSD, PCP, mushrooms)Other:Past Psychiatric HistoryPsychiatric HospitalizationsDatesLocationReasonDid it help? Y/NOutpatient & Partial Hospitalization ProgramsPsychotherapy / Talk Therapy / CounselingProviderDatesLocationType of therapyDid it help? Y/NFamily HistoryFor the following conditions, please indicate whether any one in your family has had this and who this was (or just write none or leave blank). Family MemberMedical ConditionDepressionMania, Manic-Depression or Bipolar DisorderSchizophrenia or Schizoaffective DisorderAnxietyObsessive-Compulsive DisorderAlcohol abuse or dependence (addiction)Other drug abuse or dependence (addiction): ___________________Autism or other Developmental DisorderDementia (at what age(s):__________________________________StrokeTremorAbnormal movementsThyroid problems (hypo- or hyperthyroidism)Other: Social/Educational/Work HistoryWhere were you born (city/state/country)? ____________________________________Where were you raised? __________________________________________________Where do you live now? __________________________ For how long? ___________Do you live in a: ____ House ____ Apartment ____ Other: ____________________Who else lives with you? __________________ Children (names/ages)?__________________________________________________Do your children have any medical problems? If so, what?_______________________Marital status:____Married/Committed relationship ____Divorced/separated ____Widowed ____Single ____ OtherWho do you consider your support system? _______________________________________________________________________________________________________________________________________________________________________________Employment status: ____Full-time ____Part-time (__hrs/week) ____Unemployed____Student (__full-time __part-time) ____DisabledCurrent or previous occupation:_____________________________________________Years of education: ____Degree(s) if any:___________________________________Are finances a stress for you? _____________________________________________What are your main sources of stress? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Hobbies: ______________________________________________________________Please remember to complete the symptom scales that were emailed to you. They can also be found at sure to use the 9 digit code emailed to you to access the surveys so the data can be properly saved to your name.Is there anything else you would like to share with us?Feedback for us:We are always trying to improve our assessment. Are there items you would suggest us eliminating? Are there items we should add? PLEASE FAX US THE COMPLETED PACKET IN ORDER TO MAKE AN APPOINTMENT. IF WE DO NOT RECEIVE YOUR NEW PATIENT PACKET, WE WILL BE UNABLE TO SCHEDULE YOU.THANK YOU! ................
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