Patient Name

Address

Date of Birth

Phone

Medicare Number

Health Fund Member Number

Diagnosis/Reason for referral

Previous trial of TMS Previous trial of TMS Yes No

Trial of two or more antidepressants with insufficient response or unacceptable side effects Trial of two or more antidepressants with insufficient response or unacceptable side effects Yes No

History of epilepsy/seizures History of epilepsy/seizures Yes No

History of head injury/neurosurgery History of head injury/neurosurgery Yes No

Metal or implanted devices in head or neck area Metal or implanted devices in head or neck area Yes No

Pregnancy Pregnancy Yes No

Pacemaker Pacemaker Yes No

Additional information

Referring doctor

Provider Number

Practice name/address

Practice Phone

Date