Submit a Patient Profile
If you would like to submit your profile for a future edition of the Connections newsletter, please complete the following information.

If you do not live in the United States, please go to our International website for more information.

Patient

  * required field
First Name:*
Last Name:*
Street address:*
Street address 2:
City:*
State/Province:*
ZIP/Postal code:*
Country:*
Home phone:*
E-mail:*
Date of Birth:*

Psychiatrist

  * required field
First Name:*
Last Name:*
Phone:*
Fax:*

Your Life Before VNS Therapy

How long have you had chronic or recurrent depression?

Less than 5 years
6-10 years
11-15 years
16+ years

On a scale of 1 to 5, with 1 being "not very severe" and 5 being "very severe," how would you rate your level of depression prior to VNS Therapy?

1
2
3
4
5

On a scale of 1 to 5, with 1 being "not very satisfied" and 5 being "very satisfied," how would you rate your level of satisfaction with your antidepressant treatment regimen prior to VNS Therapy?

1
2
3
4
5

Number of antidepressant medications taken at the time of VNS Therapy procedure:

0
1
2
3
4
5
More than 5

Your Life After VNS Therapy

Date received VNS Therapy [MM/DD/YYYY]

Age received VNS Therapy

How would you rate your current level of depression?

Free of Depression
Somewhat Improved
Significantly Improved
Severe, have not responded yet

Since I began VNS Therapy, I have seen improvements in:

Vitality
Emotional well-being
Daily functioning
Social interactions
Other (explain):
 

Number of antidepressant medications taking now:

0
1
2
3
4
5
More than 5

Please describe any improvements in your capacity for and/or interest in day-to-day activities:

Comments:

How long after the procedure did you start to see improvement?

3 months
6 months
9 months
1 year
2 years

Note: By submitting your information, you allow Cyberonics permission to contact you and your psychiatrist regarding the VNS Therapy Advocate program. The submission of the data does not guarantee participation in the program.

Terms and conditions

By submitting this information, you agree to the Cyberonics Terms and Conditions for use of this information. Please fill out the information listed above to the best of your knowledge.

I hereby give my permission to use my name, phone number, and diagnosis information to contact me. I understand that I may revoke this authorization in writing at any time by sending or faxing a written notice to Cyberonics, Inc., at the address attached. This authorization expires in 5 years unless earlier revoked. Cyberonics, Inc., will keep my information confidential, may not condition the sale of a device intended for my use on my completion of this authorization form, and will not receive compensation in exchange for contacting me.

 

   

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© Cyberonics, Inc. 2007  
       
  UNITED STATES INDICATION FOR USE:
The VNS Therapy System is indicated for use as an adjunctive therapy in reducing the frequency of seizures in adults and adolescents over 12 years of age with partial onset seizures, which are refractory to antiepileptic medications.

VNS Therapy (or the VNS Therapy System) is indicated for the adjunctive long-term treatment of chronic or recurrent depression for patients over the age of 18 who are experiencing a major depressive episode and have not had an adequate response to four or more adequate antidepressant treatments.