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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 Pain and Other conditions
Safety Screening for Pain and Other conditions
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TMS Safety Screening
Layout
Patient name
*
Date of birth
*
Today’s date
*
Have you undergone TMS in the past?
*
Yes
No
Other
If yes, were there any adverse reactions?
Other
Do you have epilepsy?
*
Yes
No
Other
Other
Have you ever had a convulsion or a seizure?
*
Yes
No
Other
If yes, please describe:
Other
Does anyone in your family have epilepsy?
*
Yes
No
Other
Other
Have you ever had a fainting spell or syncope?
*
Yes
No
Other
If yes, please describe the occasion(s)?
Other
Have you ever had a stroke?
*
Yes
No
Other
Other
Have you ever had a head injury or neurosurgery?
*
Yes
No
Other
If yes, was this associated with a concussion or loss of consciousness?
Other
Have you had any illness that caused brain injury?
*
Yes
No
Other
Other
Do you have metal in the brain, skull or elsewhere in your body such as shrapnel, surgical clips, splinters or fragments from welding or metal work?
*
Yes
No
Other
If so, please specify position and type of metal:
Other
Do you have a cardiac peacemaker or intracardiac lines?
*
Yes
No
Other
Other
Do you have a medication infusion device?
*
Yes
No
Other
Other
Do you have an implanted neurostimulator? (e.g. DBS, epidural/subdural, VNS)
*
Yes
No
Other
Other
Do you have any hearing problems or ringing in your ears?
*
Yes
No
Other
Other
Do you have cochlear implants?
*
Yes
No
Other
Other
Do you suffer from frequent or severe headaches?
*
Yes
No
Other
Other
Have you had retinal detachment?
*
Yes
No
Other
Other
Have you ever had any other brain-related condition?
*
Yes
No
Other
Other
Are you pregnant or is there a chance that you might be?
*
Yes
No
Other
Other
Are you taking any prescribed medication?
*
Yes
No
Other
If so, please list:
Other
Have you had any alcoholic drinks over the last 12 months?
*
Yes
No
Other
If so, please count the number of standard alcoholic drinks you would have in an average week:
1 standard drink ≈ 100mls of wine, 30mls of spirit, 1 mid strength beer
Other
Do you use recreational drugs?
*
Yes
No
Other
If so, please specify the type/s, amount and frequency:
Other
Have you ever had an electroencephalogram (EEG)?
*
Yes
No
Other
If so, what was the reason?
Other
Have you ever undergone an MRI in the past?
*
Yes
No
Other
If so, were there any issues?
Other
Thank you for your assistance. Please sign below:
Acknowledgement
*
I acknowledge that to the best of my knowledge the above answers relating to the safety of TMS treatment are accurate.
Date
*
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