Download 25-44005-000

MCG TMS Clinic Safety Screen
(To be Reviewed/Signed by TMS Attending Physician)
Date: _____/_____/_____
Patient Name:
MR#:
Screening Clinician:
Check one
Yes*
Have you ever…
…had an adverse reaction to rTMS?
…had a seizure?
…had an EEG or brain imaging (CT scan, MRI, PET scan)?
…had a stroke?
Do you have any metal in your head (outside of the mouth) such as shrapnel, surgical
clips, or fragments from welding or metalwork?
Do you have any implanted devices such as cardiac pacemakers, medical pumps, or
intracardiac lines?
Do you suffer from frequent or severe headaches?
Have you ever had any brain-related condition (other than depression)?
Have you ever had any illness or trauma that caused brain injury?
What medications do you take on a regular basis (Prescribed or Over-the-Counter)?
Do you have current pain in your head/neck/back/shoulders or other pain related to
your spine?
What medications do you take on an infrequent or “as needed” basis?
Do you grind your teeth or have temporomandibular joint disease (TMJ)?
Does anyone in your family have epilepsy?
Do you have any permanent tattoos on your head and neck?
If you are a sexually active woman, are you using a reliable method of birth control?
*Please explain any ‘YES’ answers in the comment section below or elsewhere on this form.
Comments/Attending Physician Review:
☐ Medically Appropriate for TMS Therapy
☐ Medical Issues requiring further attention:
Version 1: 2013-12-05
No
TMS Physician Signature:_________________________________________ Date:_________________