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? *YesNo

Do you have any metal or medical devices implanted in your head or chest? *YesNo

Are you pursuing TMS for Severe Depression? *YesNo

Have you received TMS before? *YesNo

Have 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, never

Have you ever worked with a psychiatrist or psychiatric prescriber?Yes, currentlyYes, in the pastNo, never

Name & clinic of current or most recent Psychiatrist or Psychiatric Prescriber:

Have you been diagnosed with a seizure disorder? *YesNo

If you answered yes to the question above, please elaborate.

Are you pursuing TMS for treating OCD? *YesNo

If you answered yes to the question above, please elaborate.

Have you ever participated in talk therapy?Yes, currentlyYes, in the pastNo, never

Does 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 birth

Phone

Email Address *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Consent *

Your privacy matters to us. Before proceeding, please take a moment to review our Privacy Policy. Here, you’ll find detailed information on how we handle, store, and protect your personal data when you submit or fill out any forms on our site.

Please do not fill in this field.

Call: 574.766.HEAL • Fax: 574.333.3200 info@thecuttingedgehealth.com

Elkhart Location
3060 Windsor Ct,
Elkhart, IN 46514

Greenwood Location
1040 Greenwood Springs Blvd,
Greenwood, IN 46143

About Us
What Makes Us Different
Conditions
Treatment
- TMS
- Blog
Providers
Employers
Contact Us