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Form 32: Transcranial Magnetic Stimulation Adult Safety Screen (TASS) Page 1 of 1
1. | Have you ever had an adverse reaction to ‘TMS? Dves
2 | Have youeverhad e seizure? ! Oves
a ~—y
3.| Have youever had an CEG? Ono Cyes
4 | Have you evertnad a stoke? Tne Oves
5 | Have you ever ha @ head injury (including neurosurgery)? On Cves
6, De youhave any metal in your hoa (outside ofthe mouth} such as shrapnel, surgical ips. oF fragments Ono Dyes
| fom weiding or metalwork? i
7 | Do you have any implanted devices such as cardiac pacemakers, medical pumps, or etracardiac lines? Ono Oves
8 | Do you suffer from frequent or severe headaches? Ono Oves
9 | Have you ever had any other brain-relaled condition? | Ono Dyes
10 | Have you ever had any ness that caused brain injury? Cn Oves
11 | Are you taking any mecications? Ono Cves
you are woman of childbearing age. are you sexually active, and iso, are you not using @ reable method
12) orbirth controt? wo Oves
an anon
12 Does anyone in your family have epilepsy?
t a
14) Do you need further explanation of ‘TMS and its associated risks? Ono Clves
“ifany tem was marked yes, please provide @ comment here
