TMS Health Questionnaire
Are you currently using any drugs or alcohol?
*
Yes
No
If so, explain:
*
Do you have any medical device implanted?
*
Yes
No
If so, explain:
*
Do you have any history of seizures?
*
Yes
No
If so, explain:
*
Do you have any neurological conditions?
*
Yes
No
If so, explain:
*
Do you have cardiovascular disease?
*
Yes
No
If so, explain:
*
Patient Name
*
First Name
Last Name
Patient DOB
*
/
Month
/
Day
Year
Signature
*
Date
*
/
Month
/
Day
Year
Submit
Should be Empty: