Treatment Resistant Depression Clinic
Services Summary
1. Your 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.
2. 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.
3. 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.
4. Treatment recommendations will be discussed with you over the phone. They will also be
written up and sent to the psychiatrist who referred you.
5. Follow-up treatment may need to be found outside of Emory
6. 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 Representative
_______________________________
Date
_________________________________
Printed Name
_______________________________
Description of Authority to Act for Patient
TRD Evaluation Clinic
New Patient Information Form
Are 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?
YES
NO
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!
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TRD Evaluation Clinic
New Patient Information Form
Emory Healthcare
Treatment-Resistant Depression Clinic
Evaluation/Consultation
New Patient Information Form
Name: _______________________________________________________________
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:
______________________________________________________________________
______________________________________________________________________
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TRD Evaluation Clinic
New Patient Information Form
History of Present Illness
Please 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?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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TRD Evaluation Clinic
New Patient Information Form
Review of Common Symptoms
For the following symptoms, please indicate whether you are currently experiencing
this, experienced this in the past, or never experienced this.
When did this occur?
Current
Past
Symptom
Depression, persistent sadness or feeling blue
Loss of pleasure in activities
Decreased motivation
Crying spells
Lack of energy or fatigue
Loss of appetite
Difficulty falling asleep
Waking up multiple times during the night
Awake early and cannot return to sleep
Increased sleep
Not eating or weight loss without trying to lose weight
Difficulty concentrating
Memory problems
Anxious or restless
Irritable mood
Feelings of guilt or worthlessness
Low self-esteem
Feelings of hopelessness
Aggressive/combative behavior
Panic or anxiety attacks
Anxiety about social situations (such as speaking in public)
Trouble with self-care (such as dressing or bathing)
Racing thoughts
Talking more than usual
Increased activity (such as writing, cleaning, or exercising more)
Increased risk-taking behavior
Obsessive thoughts (symmetry, cleanliness, intrusive thoughts)
Intrusive thoughts about something bad that happened to you
Compulsive behaviors (counting, washing hands, cleaning)
Paranoia (suspiciousness)
Reading other people’s thoughts
Feeling that your thoughts are being read
Feeling like the television or radio is talking to you specifically
Seeing or hearing something that others can’t
Not eating in order to lose weight
Exercising to lose weight
Using laxatives to lose weight
Using other methods to lose weight: ___________________________
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TRD Evaluation Clinic
New Patient Information Form
Overeating without feeling hungry
Binging (eating large amounts)
Trauma
Have 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 Medications
Please 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.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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TRD Evaluation Clinic
New Patient Information Form
Prior treatments
Please 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).
Treatment
When
Where
How many
sessions
Outcome
Did it help?
Y/N or
do not know
Electroconvulsive
Therapy (ECT)
Right unilateral
ECT Bifrontal
ECT Bitemporal
Transcranial
Magnetic
Stimulation
(rTMS)
Transcranial
Direct-Current
Stimulation
(tDCS)
Vagal Nerve
Stimulation (VNS)
Ketamine
Infusions
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TRD Evaluation Clinic
New Patient Information Form
Past Medical History
For the following medical conditions, please indicate whether this is a current problem, a
past problem, or never a problem.
When was this a problem?
Current Past
Never
Medical Condition
High blood pressure
Heart disease
Breathing problems (such as asthma or COPD)
Diabetes
Cancer: _________________________________________________
Thyroid problems (hypo- or hyperthyroidism)
Acid reflux
High cholesterol
Sleep apnea
Seizures
Stroke
Tremor
Abnormal movements
Fainting
Eye problems: ____________________________________________
Chronic pain (such as back pain or other joint pain): ______________
Anemia or other blood disorder
Chronic infectious disease (such as herpes, HIV, hepatitis): ________
Other:
Past Surgical History
Please describe any surgical procedure you have had and what it was for:
______________________________________________________________________
______________________________________________________________________
Allergies/Adverse Drug Reactions
Please describe any drug, food or other allergies:
______________________________________________________________________
______________________________________________________________________
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TRD Evaluation Clinic
New Patient Information Form
Review of Common Physical Symptoms
Please indicate whether you have any of the following symptoms AT THIS TIME.
Symptom
Fatigue or feeling ill (malaise)
Weight loss or gain
Fever or chills
Sweating
Swollen or painful lymph nodes
Cough
Wheezing
Coughing or spitting up blood
Chest pain at rest
Chest pain with activity
Palpitations, heart pounding or heart racing
Swollen ankles
Shortness of breath at rest
Shortness of breath with activity
Dizziness of fainting
Headaches or migraines
Frequent falls
Balance problems
Difficulty walking
Tremor
Numbness or tingling in fingers or toes
Change in handwriting
Snoring
Forgetfulness or other memory problems
Feeling confused
Change in speech or voice
Change in ability to smell
Change in ability to hear
CURRENTLY EXPERIENCING
Change in ability to taste
Change in ability to see
Eye pain
Blurred or double vision
Difficulty swallowing
Heartburn or acid reflux
Stomach or intestinal pain before or after eating
Stomach or intestinal pain at rest
Feeling of heaviness or fullness in abdomen
Constipation
Diarrhea
Nausea or vomiting
Vomiting blood
Bloody stools or blood in stool
Very dark or “tar-like” stools
Difficulty getting or maintaining an erection
Premature ejaculation
Prolonged erection without ejaculation
Pain with intercourse
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TRD Evaluation Clinic
New Patient Information Form
Decreased libido
Problems with urination (painful or slow)
Urinating frequently
Urinary incontinence (difficulty holding your urine)
Increased thirst
Dry mouth or eyes
Unable to tolerate heat or cold
Changes in color or texture of hair
Hair loss
Increased hair growth
Change in height, head size, hand size or shoe size
Muscle, bone or joint pain or stiffness
Difficulty standing from a sitting position
Excessive bleeding or easy bruising
Recurrent infections or difficulty recovering from
infections
Dry skin
Other skin changes
Rash
New moles or change in existing moles
Lumps under skin
Other symptoms:
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TRD Evaluation Clinic
New Patient Information Form
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 Class
Generic
Name
Year drug was Highest Dose
tried
# Weeks drug
was taken
Was it
helpful
(Y/N)?
Did you experience Did you stop due to
side effects (Y/N)?
side effects?
SSRI
Luvox
Fluvoxamine
Paxil
Paroxetine
Prozac
Fluoxetine
Zoloft
Sertraline
Celexa
Citalopram
Lexapro
Escitalopram
SNRI
Effexor
Venlafaxine
Cymbalta
Duloxetine
Pristiq
Desvenlafaxine
Savella
Milnacipram
Fetzima
Levomilnacipram
Anticonvulsant
Lithium
Tegretol
carbamazepine
Depakote
Divalproex
Neurontin
Gabapentin
Lamictal
Lamotigine
Trileptal
Oxacarbazepine
Depakote
valproate
Depakene
valproic acid
Antipsychotics
Abilify
Aripiprazole
Saphris
Asenapine
Clozaril
Clozapine
Fanapt
Iloperidone
Latuda
Lurasidone
Zyprexa
Olanzapine
Invega
Paliperidone
Seroquel
Quetiapine
Risperdal
Risperidone
Geodon
Ziprasidone
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TRD Evaluation Clinic
Drug Class
Generic
Name
Year drug was Highest Dose
tried
New Patient Information Form
# Weeks drug
was taken
Was it
helpful
(Y/N)?
Did you experience Did you stop due to
side effects (Y/N)?
side effects?
Sedatives and Sleeping Agents
Klonopin
Clonazepam
Xanax
Alprazolam
Valium
Diazepam
Benadryl
Diphenhydramine
Lunesta
Eszopiclone
Ativan
Lorazepam
Serax
Oxazepam
Restoril
Temazepam
Trazodone
Halicon
Triazolam
Sonata
Zaleplon
Ambien
Zolpidem
Augmenting
Buspar
Buspirone
Cytomel
Lioothyronine
Omeha 3 FA
Stimulants
Nuvigil
Armodafinil
Adderal
amphetamine
Vyvanase
Ritalin
Lisdexamphetamin
e
Methylphenidate
Provigil
Modafinil
Other
Strattera
Atomaxetine
Wellbutrin
Bupropion
Remeron
Mirtazapine
Serozone
Nefazodone
Edronax
Reboxatine
Stablon
Tianeptine
Vibryd
Vilazodone
Brintellix
Vortioxetine
TCA
Adapin
Doxepin
Anafranil
Clomipramine
Asendin
Amoxapine
Endep/Elavil
Amitriptyline
Ludiomil
Maprotiline
Norpramin
Desipramine
Pamelor
Nortyrptiline
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TRD Evaluation Clinic
Drug Class
Generic
Name
Sinequin
Doxepin
Surmontil
Trimipramine
Tofranil
Imipramine
Vivactil
Protryptiline
Azafen
Pipofezine
New Patient Information Form
Year drug was Highest Dose
tried
# Weeks drug
was taken
Was it
helpful
(Y/N)?
Did you experience Did you stop due to
side effects (Y/N)?
side effects?
Agedal/Eltrono Noxiptiline
Merival/Alival
Nomifensine
MAOIs
Marplan
Isocarboxazid
Nardil
Phenelzine
Parnate
Tranylcypromine
Emsam
Selegiline patch
Aurorix
Moclobemide
Pirazidol
Pirlindone
Substances
For each of the substances below, please indicate how often you use/have used it.
Substance
Used in past
Use currently
How much?
How many times per
week?
Alcohol
Nicotine
Caffeine
Cocaine
Marijuana
Heroin
Other opiates
Barbiturates
Benzodiazepines
(e.g., Valium)
Amphetamines
Hallucinogens (e.g.,
LSD, PCP,
mushrooms)
Other:
Past Psychiatric History
Psychiatric Hospitalizations
Version date: 01/11/2016
Dates
Location
Reason
Did it help? Y/N
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TRD Evaluation Clinic
New Patient Information Form
Outpatient & Partial
Hospitalization Programs
Psychotherapy / Talk Therapy / Counseling
Provider
Dates
Location
Type of therapy
Did it help? Y/N
Family History
For 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 Member
Version date: 01/11/2016
Medical Condition
Depression
Mania, Manic-Depression or Bipolar Disorder
Schizophrenia or Schizoaffective Disorder
Anxiety
Obsessive-Compulsive Disorder
Alcohol abuse or dependence (addiction)
Other drug abuse or dependence (addiction): ___________________
Autism or other Developmental Disorder
Dementia (at what age(s):__________________________________
Stroke
Tremor
Abnormal movements
Thyroid problems (hypo- or hyperthyroidism)
Other:
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TRD Evaluation Clinic
New Patient Information Form
Social/Educational/Work History
Where 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
____Widowed
____Single
____Divorced/separated
____ Other
Who do you consider your support system? ___________________________________
______________________________________________________________________
______________________________________________________________________
Employment status: ____Full-time
____Part-time (__hrs/week)
____Student (__full-time __part-time)
____Unemployed
____Disabled
Current or previous occupation:_____________________________________________
Years of education: ____ Degree(s) if any:___________________________________
Are finances a stress for you? _____________________________________________
What are your main sources of stress? ______________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Hobbies: ______________________________________________________________
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TRD Evaluation Clinic
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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!
Version date: 01/11/2016
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