TMS Screening Form Please answer the questions honestly and to the best of your ability. There are no “right” or “wrong” answers. These questions are a baseline for further medical investigation to determine if TMS is the correct next step for you. Are you 18 years old or older? *YesNoDo you have any metal or medical devices implanted in your head or chest? *YesNoAre you pursuing TMS for Severe Depression? *YesNoHave you received TMS before? *YesNoHave you taken medications for depression and/or OCD (including current and past)? If yes, how many?Yes, 4 or more different kinds.Yes, 2 to 3 different kinds.Yes, only 1No, neverHave you ever worked with a psychiatrist or psychiatric prescriber?Yes, currentlyYes, in the pastNo, neverName & clinic of current or most recent Psychiatrist or Psychiatric Prescriber:Have you been diagnosed with a seizure disorder? *YesNoIf you answered yes to the question above, please elaborate.Are you pursuing TMS for treating OCD? *YesNoIf you answered yes to the question above, please elaborate.Have you ever participated in talk therapy?Yes, currentlyYes, in the pastNo, neverDoes your current psychiatrist or psychiatric prescriber know you are pursuing TMS?Yes, they referred me to you.Yes, we discussed in the past.No, they aren't aware, but I understand that you may communicate with them to determine my eligibility for TMS.First Name *Last Name *Date of birthPhoneEmail Address *Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeSubmit
