Screening form

First Name *

Last Name *

Email *

Number *

Date of Birth *

Address *

GP Contact Details *

Gender *

Pregnancy

Technical Questions

Have ever had complication from an MRI?

How long have you been suffering from depression? *

Do you suffer from insomnia *

Have you experienced a seizure within the last 12 months? *

Daily caffeine intake:

Recreational drugs?

Daily alcohol intake?

How long have you been suffering from anxiety? *

Medication taken for depression and/or anxiety?

Do you have epilepsy? *

Do you suffer from migraines? *

Are you currently on any other medication other than anti-depressants?

Please note any other relevant information here:

Email

The rTMS Centre (London) • 307 Regents Park Rd, Finchley, London N3 1DP • 020 7205 2072

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