Screening Form

Full Name*

Date of Birth*

Email*

Contact Number*

Address*

Gender*

Pregnancy

Presence of electronic implants (e.g. cochlear implant, pacemaker, insulin pump, clips)*

Have ever had complication from an MRI?

Condition enquiring for.*

Description of Symptoms*

Pharmacological treatments undertaken?*

History of epileptic episode?*

Suffering from insomnia*

Suffering from migraine?*

Daily caffeine intake:

Daily alcohol intake?

Recreational drugs?

When you prefer your treatment to start?

Please let us know how you found us?

Name

The rTMS Centre (London) • 4 Devonshire Street, London W1W 5DT • 020 7205 2072

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Brain Stimulation Therapies