TMS Screening Form

TMS Screening Form

Your head will be exposed to a strong MRI strength pulse. To maximize safety, please answer the questions below. Please do not hesitate to ask any questions you may have.
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you, or have ever had, any of the following?
1. Cardiac pacemaker or cardiac implant.
2. Previous brain neurosurgery
3. Metallic hardware in or around your head (metal plate, metal screws, metallic ink tattoos).
4. Any electrical, mechanical, or magnetic implants (Cochlear implant, Vagus Nerve Stimulator)
5. Implanted medication pumps, Intracardiac line or central venous catheter.
8. Migraine headaches.
7. Prior diagnosis of seizure or epilepsy in family history.
6. History of cortical stroke or other cortical lesion (brain tumor)
11. Any metal on your body (i.e. hair holders, hair pins, eyeglasses, piercings, etc)
If yes, these will need to be removed before treatment
9. Any chance of pregnancy.
10. Unstable medical conditions (such as schizophrenia, schizoaffective Disorder, Bipolar Disorder 1 or 2, Eating Disorders, etc.
Initials
Date

MonthDayYear

Rows	Not at all	Several Days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

Do you, or have ever had, any of the following?