HealMed Clinic

TMS Informed Consent Form

Before you are able to receive TMS treatment, we need to make sure that it is safe for you to do so. To that end, we need information about the possible factors that could enhance your risk to experience unintentional adverse effects. Please fill out the questionnaire carefully and honestly. This form will subsequently be assessed by a physician.

Please also sign at the bottom of each page

Screening Questionnaire

1) Do you have epilepsy?
2) Have you ever had a convulsion or a seizure?
3) Does someone in your family have epilepsy?
4) Have you ever lost consciousness without any known reason?
5) Have you ever had a severe head trauma?
6) Have you ever had a stroke?
7) Have you ever undergone surgery to your head?
8) Do you have any of the following implants in your body:
9) Do you have any deviations of the spinal cord, bone marrow, or the ventricular system (spaces in the brain filled with liquid)?
10) Do you have any hearing disabilities or ringing in your ears?
11) Have you ever (at present or in the past) suffered from a brain-related, neurological illness?
12) Do you suffer from frequent severe headaches?
13) Are you currently under any form of medical treatment?
14) Are you currently taking antibiotics (a medication that helps alleviate bacterial infections)?
15) Do you ever take antihistamines (anti-allergy medication)?
16) Are you taking any other medications not mentioned above?
17) Do you have a chronic illness/disorder?
18) Have you ever (at present or in the past) had a psychiatric-based illness/disorder?
19) Does someone in your family have a psychiatric-based illness/disorder?
20) Have you used any recreational drugs during the past year (such as marijuana, ecstasy, cocaine, etc.)?
22) Have you ever suffered from substance dependence or abuse?
23) Do you averagely consume more than 3 alcoholic units a day?
24) Do you have sleeping problems?
25) Are you pregnant, or is there a chance that you might be?
26) Have you ever undergone an MRI for clinical purposes?
27) Have you ever undergone TMS?

Informed Consent for TMS Treatment

I answered all questions truthfully and to the best of my knowledge and belief. If deemed medically appropriate by my physician, I consent to undergo transcranial magnetic stimulation under the care and direction of my physician.