Screening Questionnaire

Your Name *

Email *

Do you have epilepsy or have you ever had a convulsion or a seizure? *

Have you ever had a fainting spell or syncope? *

If yes, please give further information

Have you ever had a head trauma that was diagnosed as a concussion or was associated with loss of consciousness?

Do you have any hearing problems or ringing in your ears?

Do you have cochlear implants?

Are you pregnant or is there any chance that you might be?

Do you have metal in the brain, skull or elsewhere in your body (e.g., splinters, fragments, clips, etc.)?

If so, specify the type of metal.

Do you have an implanted neurostimulator? (e.g., DBS, epidural/subdural, VNS)

Do you have a cardiac pacemaker or intracardiac lines?

Do you have a medication infusion device?

Are you taking any medications?

If so, please list

Did you ever undergo TMS in the past?

If so, were there any problems.

Did you ever undergo MRI in the past?

If so, were there any problems.

Have you received any medication or other treatment for fibromyalgia in the past?

What treatment/medication?

When/for how long?

Did it help?

Side effects?

Please confirm your consent *

I confirm that the information I have given is correct and that I give permission for my data to be transmitted via this form

Screening Questionnaire for Transcranial Magnetic Stimulation (TMS)