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Neurology Clinic
Services
About
Contact
SURVEY
Is TMS Right For Me?
Step
1
of
6
16%
1. What condition(s) are you interested in treating with TMS?
Depression
Anxiety
PTSD
Memory loss
Brain fog
Insomnia
ADHD
Post-concussion syndrome
Other, please specify
Please Specify
(Required)
2. Do you have any of the following (check all that apply)
Pacemaker or Implanted cardioverter defibrillator (ICD)
Aneurysm clips/coils
Brain stents
Deep brain stimulator
CSF shunt
Seizure within the past year
Wear thick locs or semi-permanent hairpieces
3. Have you been medically treated for the condition(s) you wish to treat?
Yes, please elaborate:
No
Please Elaborate:
4. Are you currently under the care of a psychiatrist or mental health provider?
Yes, please provide name:
No
Please provide name
5. Please list any medications that you are currently taking for the conditions you wish to treat:
Full Name:
E-mail:
Phone No:
