TMS Evaluation Form

Austin Mind and Behavioral Health

Please help us determine whether TMS Therapy is right for you by completing the following questionnaire. If you have any questions, please feel free to ask us at any time.

Personal Information
Name(Required)
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Address(Required)
Questionnaire
1. Have you been treated with TMS in the past?
2. Do you have any metallic objects in your head or anywhere else in your body? These can include aneurysm clips or coils, stents, implanted stimulators, electrodes to monitor your brain activity, ferromagnetic implants in your ears or eyes, bullet fragments, other metal devices or objects implanted in the head, facial tattoos with metal ink or permanent makeup
3. Do you currently take drugs or medication of any kind?
4. Have you had an epileptic seizure in the past?
5. Has anyone in your immediate family had an epileptic seizure?
6. Have you suffered a traumatic brain injury or other serious head injury? This can include vascular, traumatic, tumoral, infectious, or metabolic lesions of the brain.
7. Have you ever suffered a stroke?
8. Is pregnancy a possibility?
9. Do you have implants or prostheses of any kind?
10. Do you carry a pacemaker or implantable cardioverter defibrillators?
11. Do you use any drugs/substances currently or have used in the last 15 days?

With my signature below, I acknowledge that I have read and answered the questions.

Clear Signature
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