Transcranial Magnetic Stimulation Adult Safety Screen (TASS)
Name:
Date:
1. Have you ever had an adverse reaction to rTMS?
No
Yes
2. Have you ever had a seizure?
No
Yes
3. Have you ever had an EEG?
No
Yes
4. Have you ever had a stroke?
No
Yes
5. Have you ever had a head injury (including neurosurgery)?
No
Yes
6. Do you have any metal in your head (outside of the mouth) such as shrapnel, surgical dips, or fragments from welding or metalwork?
No
Yes
7. Do you have any implanted devices such as cardiac pacemakers, medical pumps, or intracardiac lines?
No
Yes
8. Do you suffer from frequent or severe headaches?
No
Yes
9. Have you ever had any other brain-related condition?
No
Yes
10. Have you ever had any illness that caused brain injury?
No
Yes
11. Are you taking any medications?
No
Yes
12. If you are woman of childbearing age, are you sexually active, and if so, are you not using a reliable method of birth control?
No
Yes
13. Does anyone in your family have epilepsy?
No
Yes
14. Do you need further explanation of rTMS and its associated risks?
No
Yes
If any item was marked 'yes', please provide a comment here:
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