Appendix B - Tms Medical Screening Questionnaire - MAGSTIM 3190-00 Operating Manual

APPENDIX B - TMS MEDICAL SCREENING QUESTIONNAIRE

The Magstim Company Limited takes your health and safety very seriously and as such, it is necessary to point out that there
is a remote possibility of adverse effects occurring as a result of receiving Transcranial Magnetic Stimulation (TMS). Such
effects can include a risk of seizure, headache, pain and nausea in particular susceptible individuals. We therefore kindly ask
that you complete the following medical questionnaire, answering each question accurately. Please read each question
carefully and if you have any doubt as to how to answer any question please tick 'yes'
No.
1. Do you have epilepsy or have you ever had a
convulsion or a seizure?
2. Does any first degree member of your family have
epilepsy?
3. Have you ever had a fainting spell?
4. Have you ever had severe (i.e., followed by loss of
consciousness) head trauma?
5. Do you have any hearing problems or ringing in your
ears? (Advise earplugs must be worn as possible risk
of temporary tinnitus)
6. Are you pregnant or is there any chance that you
might be?
7. Do you have metal in the brain/skull (except
titanium)? (e.g. splinters, fragments, clips, etc.)
8. Have you had surgery in the last 12 months above the
neck?
9. Do you have a cochlear implant?
10. Do you have an implanted neurostimulator? (e.g.,
DBS, epidural, subdural, VNS)
11. Do you have a cardiac pacemaker or intracardiac lines
or metal in your body?
12. Do you have a medication infusion device?
13. Are you taking any medications such as anti-
depressants, psychoactive, neurological, psychiatric,
recreational drugs?
14. Have you consumed alcohol within the last 12 hours?
(Please use the guidelines in the Procedure if answer is
yes).
15 Have you ever have a surgical procedure to your
spinal cord?
16. Do you have spinal problems?
17. Have you undergone TMS in the past and had any
adverse affects?
18. Have you had a reasonable night's sleep?
© The Magstim Company Limited
QUESTION
YES NO DON'T
KNOW
22
Magstim 2nd Generation Coils
Operating Manual
COMMENTS
MOP04-EN-03