TMS SAFETY CHECKLIST

1. Have you ever experienced Transcranial Magnetic Stimulation (TMS)? YES/NO

If YES, did you observe any side effect? YES/NO

If YES, describe the side effects:

2. Have you ever had vertigo, fainting, or black outs? YES/NO

If YES, describe in which occasion(s):

3. Have you ever had an epileptic seizure? YES/NO

4. Do you or any member of your family suffer from epilepsy? YES/NO
5. Do you regularly have headaches or migraine? YES/NO
6. Do you have hearing problems or have you ever lost your hearing? YES/NO
7. Have you ever had a stroke? YES/NO
8. Have you ever been told that your blood pressure was abnormal? YES/NO
9. Have you ever had a head trauma? YES/NO
10. Have you ever had neurosurgery or any other type of surgery? YES/NO
If YES, specify:

11. Do you have a medical condition (diabetes, asthma, or heart disease)? YES/NO
12. Do you take any medication (except from contraception)? YES/NO
If YES, specify:

13. Do you have any implanted device (electronic, mechanical or magnetic) YES/NO
such as: pacemaker, medical pump, surgical clip, cochlear implant, or
anything else?
14. Have you ever been injured by metal fragments or worked with YES/NO
machines without eye protection?
15. If you are a woman, is there any chance you are pregnant? YES/NO
16. Is there anything else we should know? YES/NO
If YES, specify:

17. Do you need more information about TMS and associated risks? YES/NO

Thousands of healthy subjects and patients have already undergone TMS allowing the relative
risks to be assessed. The occurrence of seizures (i.e., the most serious acute TMS-related side
effect) has been extremely rare, and in those few cases, subjects answered ‘YES’ to one or
more questions.

I have read and understood all the questions and declare that to the best of my knowledge the
above information is correct.

Date ___________________ Signature ___________________