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Screening form
Full Name
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Email
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Phone Number
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Date of birth
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Address
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GP contact details
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Gender
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Female
Male
Are you pregnant
Yes
No
N/A
Technical Questions - Please select any that apply.
Aneurysm clips or coils
Cardiac pacemaker or wires
Internal cardioverter defibrillator (ICD)
Carotid or cerebral stents
Deep brain stimulator
Metallic devices implanted in your head
Dental implants
Cochlear implant/ear implant
CSF (cerebrospinal fluid) shunt
Eye implants
Cardiac stents, filters, or metallic valves
Vagus nerve stimulator (VNS)
Blood vessel coil
Medication patch/nicotine patch
Wearable cardioverter defibrillator
Implanted insulin pump
Programmable shunt or valve
Hearing aid
Cervical fixation devices
Surgical clips, staples, or sutures
VeriChip micro transponder
Wearable monitor (e.g., heart monitor)
Bone growth stimulator
Wearable infusion pump
Radioactive seeds
Portable glucose monitor
Tracheostomy
Have you ever had complication from an MRI?
Yes
No
How long have you been suffering from depression / Anxiety?
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Are you currently taking medication for depression/Anxiety?
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Yes
No
Please specify brand/name of medication taken for depression/anxiety
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How many different medications taken?
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Do you have epilepsy?
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Yes
No
Have you experienced a seizure within the last 12 months?
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Yes
No
If yes how long did the seizure episode last?
Do you suffer from migraines and/or continuous headaches?
*
Yes
No
Do you suffer from Insomnia?
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Yes
No
Daily alcohol intake:
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Daily caffeine intake:
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Drug Abuse:
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Are you currently on any other medication other than anti-depressants?
Other relevant information:
If you are human, leave this field blank.
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