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Pioneer Health TMS
2 Pioneer Road, Centennial Park, WA 6330
Monday to Thursday : 8:00am - 8:00pm Friday : 8:00am - 5:30pm
tms@pioneerhealth.com.au
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(08) 9842 2822
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Menu
Home
About Us
Services
Services
Depression
Pain
Smoking Cessation
Other conditions
FAQ
FAQ
Risks
Health Professionals
Contact Us
Safety Screening for Depression
Safety Screening for Depression
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TMS Safety Screening
Layout
Patient name
*
Date of birth
*
Today’s date
*
Past history:
Layout
Cochlear implant
*
No
Yes
Details
Epilepsy or Past seizures
*
No
Yes
Details
Family history of seizures
*
No
Yes
Details
Fainting/Syncopal episodes
*
No
Yes
Details
Eye injuries
*
No
Yes
Details
Head injuries or past neurosurgery
*
No
Yes
Details
Chronic severe headaches
*
No
Yes
Details
Stroke
*
No
Yes
Details
Implanted electrodes or neurostimulators eg. Deep brain stimulator, Vagus Nerve Stimulator
*
No
Yes
Details
Pacemaker orIntra-cardiac lines
*
No
Yes
Details
Implanted Cardioverter Defibrillator(ICD) or Wearable Cardioverter Defibrillator
*
No
Yes
Details
Aneurysm clips/coils
*
No
Yes
Details
Stents
*
No
Yes
Details
Cerebral Spinal Fluid Shunt
*
No
Yes
Details
Metallic devices or foreign bodies in the head or neck region (eg. Shrapnel or fragments from metal work/welding
*
No
Yes
Details
Facial tattoos w/ metallic ink
*
No
Yes
Details
Metallic devices implanted in head
*
No
Yes
Details
Medication infusion device
*
No
Yes
Details
Current pregnancy
*
No
Yes
Details
Past treatments:
Previous TMS:
*
No
Yes
Any complications?
Previous ECT:
*
No
Yes
Number of treatment sessions, effectiveness, and adverse effects.
Past investigations:
Past EEGs:
*
No
Yes
Findings?
Past MRIs:
*
No
Yes
Any complications?
Medication:
Do you take any prescribed medication?
*
No
Yes
Please list:
Have you had any recent changes to your medication?
*
No
Yes
Details
Drug and Alcohol use:
Alcohol
*
No
Yes
Type of alcohol & Standard drinks per week:
Recreational drugs
*
No
Yes
Type of recreational drug & Amount used per week:
Acknowledgement
*
I acknowledge that the above information regarding my medical history in relation to the safety of TMS treatment is complete and accurate.
Patient name
*
Date
*
Submit
