TMS Pre-Treatment Safety Checklist

First Name *

Last Name *

Mood & Anxiety Rating

Have you completed a "Mood and Anxiety Rating Scale" in the last week? *

YesNo

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

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 any of the above cannot be confirmed, please discuss with the TMS team prior to submitting this form

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

Name

Signature *

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Date