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Location: Central London
Location: Central London
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Screening Form
Full Name
*
Date of Birth
*
Email
*
Contact Number
*
Address
*
Gender
*
Female
Male
Pregnancy
N/A
Yes
No
Presence of electronic implants (e.g. cochlear implant, pacemaker, insulin pump, clips)
*
Have ever had complication from an MRI?
No
Yes
Condition enquiring for.
*
Description of Symptoms
*
Pharmacological treatments undertaken?
*
History of epileptic episode?
*
Yes
No
Suffering from insomnia
*
Yes
No
Suffering from migraine?
*
Yes
No
Daily caffeine intake:
Daily alcohol intake?
Recreational drugs?
When you prefer your treatment to start?
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