Patient Intake Form

The TMS medical intake questionnaire. Patients fill this out on their phones or tablets.

How to Access

For staff: Dashboard → Begin Intake

For patients: Click the unique link sent by staff

Form Structure

Section 1: Demographics & Safety

Basic Information:

  • Full name
  • Date of birth
  • Contact information (email, phone)
  • Insurance details

Safety Screening:

  • Metal implants (pacemakers, cochlear implants)
  • History of seizures
  • Pregnancy status
  • Current medications

This section determines if patient is safe for TMS treatment.

Section 2: Medical History

Current Medications:

  • List all medications
  • Dosage and frequency
  • Duration taking each medication

Medical Conditions:

  • Past psychiatric diagnoses
  • Previous treatments tried
  • Hospitalizations
  • Substance use history

Family History:

  • Mental health conditions in family
  • Neurological conditions

Section 3: Providers & Treatment Goals

Care Team:

  • Primary care physician
  • Psychiatrist/prescriber
  • Therapist
  • Other specialists

Treatment Information:

  • Referring provider
  • Reason for TMS referral
  • Previous treatment attempts
  • What patient hopes to achieve

Insurance:

  • Insurance carrier
  • Policy number
  • Authorization status

Features

Auto-Save

Form automatically saves progress every few seconds.

Patient can close browser and return later - their progress is saved.

Progress Indicator

Top of form shows current section and overall progress.

Validation

Required fields marked with red asterisk.

Form won’t let you skip required questions.

Invalid entries (wrong date format, etc.) show error messages.

Mobile Optimized

Form works on any device:

  • Phone (most common)
  • Tablet
  • Desktop

Large touch targets, easy to read on small screens.

After Submission

Patient sees confirmation message:

  • “Your intake has been submitted”
  • Timestamp of submission
  • What happens next

Staff gets notified of new submission in admin portal.

Time to Complete

Typically 10-15 minutes.

Can be completed in multiple sessions if needed.

Privacy

All data encrypted. HIPAA compliant.

Form data never leaves secure servers.