TRANSCRANIAL MAGNETIC STIMULATION ADULT SAFETY SCREEN

Please read all questions carefully and answer all questions honestly. All responses will be kept strictly
confidential.

1. Have you ever had an adverse reaction to TMS? YES NO

2. Have you ever had a seizure? YES NO

3. Have you ever had an EEG? YES NO

4. Have you ever had a stroke? YES NO

5. Have you ever had a head injury (include neurosurgery) YES NO

Do you have any metal in your head (outside of the mouth) such as Shrapnel, YES NO
6. surgical clips or fragments from welding or metalwork?
Do you have any implanted devices such as cardiac pacemakers, Medical YES NO
7. pumps, or intracardiac lines?

8. Do you suffer from frequent or severe headaches? YES NO

9. Have you ever had any other brain-related condition? YES NO

10. Have you ever had any illness that caused a brain injury? YES NO

11. Are you taking any medications? YES NO

If you are you a woman of childbearing age, are you sexually active, And if so, YES NO
12. are you not using a reliable method of birth control?

13. Does anyone in your family have epilepsy? YES NO

14. Do you need further explanation of TMS and its associated risks? YES NO

Adapted from: Keel JC, Smith MJ, Wassermann EM. A safety screening questionnaire for transcranial magnetic stimulation. Clin Neurophysiol.
2001;112:720.

Signature Signature
Investigator: Participant:

Date: Date: