TMS Questionnaire

Personal Information *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Have you been diagnosed with Major Depressive Disorder? *

Yes

No

Have you ever been treated with TMS Therapy? *

Yes

No

Are you pregnant or is there any chance that you might be? *

Yes

No

Do you currently take drugs or medication of any kind? *

Yes

No

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

Yes

No

Have you taken medication for your symptoms of depression? *

Yes

No

Have you changed medications more than once due to ineffectiveness or negative side effects? *

I have only tried one type of antidepressant

I have tried 2 or more types of antidepressants

No

Have you or anyone in your immediate family ever have an epileptic seizure? *

Yes, I have

Yes, an immediate family member

No

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.

Yes

No

Do you implants or prostheses of any kind? *

Yes

No

Do you have a medication infusion device?

Yes

No