TMS Pre-Treatment Safety Checklist

First Name *

Last Name *

Medicare Requirement

In order to continue getting the Medicare rebate, Medicare will need proof that a certain number of online "Mood and Anxiety Rating Scales" have been completed. This will usually takes around 5 minutes. Please click the following button:

Mood and Anxiety Rating Scale

Mood & Anxiety Rating

Safety Checklist

Have you had any NEW SIDE EFFECTS since your last TMS treatment? *

Yes No

Provide further details of the side effects experienced

Have you had any MEDICATION CHANGES since your last TMS session *

YesNo

Provide further details of medication changes

Have you had any SEIZURES or faints (syncope) since your last TMS treatment? *

Yes No

Provide further details of the seizures and/or fainting (syncope)

Have you consumed more than 4 standard ALCOHOLIC DRINKS in the last 24 hours? *

Yes No

Provide further details (i.e: number of drinks consumed, time of last drink) below *Please note - the TMS clinician will not administer any treatment if you present to the appointment intoxicated

Do you have any symptoms of alcohol/benzodiazepine WITHDRAWAL (eg. tremors, excessive sweating, palpitations)? *

Yes No

Provide further details of withdrawal symptoms *

Have you had LESS than FOUR hours of SLEEP for the past THREE CONSECUTIVE NIGHTS? *

Yes No

Provide further details for sleep below *

Provide further details of any issues from last appt

Are you PREGNANT to the best of your knowledge? *

Yes NoN/A

Preparing for Treatment

I have removed all jewellery, facial piercings, hearing aids, electronic devices and all metal objects. *

I have answered all Safety Checklist questions accurately to the best of my knowledge. *

I confirm that I am NOT at risk of harming myself or others, and can guarantee my safety *

If you cannot confirm any of the above, please speak to your TMS nurse prior to submitting this form

Please note that in certain circumstances it may not be appropriate to continue with your treatment session today.

In these cases, we will endeavour to contact you as soon as practicable to discuss this further.

Patient Signature *

Draw signature|Type signatureClear

Date