Transcranial Magnetic Stimulation (TMS) study participant registration form

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Please complete the form below.

Name *

Contact Number *

Email Address

Gender *

Male

Female

Do you have epilepsy or have you ever had a convulsion or a seizure? *

Yes

Have you had a fainting spell or syncope during the last 6 months?
*

Yes

Have you ever had severe (i.e., followed by loss of consciousness) head trauma?
*

Yes

Do you have any hearing problems or ringing in your ears?
*

Yes

Are you pregnant or is there any chance that you might be?

Yes

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Do you have metal in the brain/skull (except titanium)? (e.g., splinters, fragments, clips, etc.)
*

Yes

Do you have cochlear implants?
*

Yes

Do you have an implanted neurostimulator? (e.g., DBS, epidural/subdural, VNS)
*

Yes

Do you have a cardiac pacemaker or intracardiac lines or metal in your body?
*

Yes

Do you use a medication infusion device?
*

Yes

Are you taking any medication for a neurological or psychiatric disease?
*

Yes

Did you ever have any surgical procedures on your brain or spinal cord?
*

Yes

Do you have spinal or ventricular derivations (e.g., ventricular shunt)?
*

Yes

Are you currently treated with immunosuppressants or anti-cancer drugs?
*

Yes

Did you ever undergo TMS in the past?
*

Yes

Did you ever undergo MRI in the past?
*

Yes

Any questions for us?

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