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Brain Body Balance TMS
Neurology Clinic
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About
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Brain Body Balance TMS
Neurology Clinic
- Services
About
Contact

SURVEY

Is TMS Right For Me?

Step 1 of 10

10%

1. What condition(s) are you interested in treating with TMS?

Mild cognitive impairment/Alzheimer’s disease

Migraine Headaches

Insomnia

Neuropathy

Post-stroke rehab

ADD/ADHD

Anxiety

Depression

Fibromyalgia

Chronic pain

Traumatic brain injury

Essential tremor

Parkinson’s Disease

Multiple sclerosis

Other

Please Specify(Required)

"Unfortunately, based on your response, TMS may not be a safe treatment option for you. Please explore other treatment options we offer that may be better suited for you"

2. Do you have any of the following (check all that apply)

Pacemaker or Implanted cardioverter defibrillator (ICD)

Cochlear implant

Aneurysm clips/coils

Brain stents

Implanted devices in head

Deep brain stimulator

Vagus nerve stimulator

Implanted electrodes/stimulator, device leads

Magnetically activated dental implants

CSF shunt

Pellets, bullet fragments

Facial tattoos with metallic ink

Other

3. Have you ever had a convulsion or a seizure?

Yes

No

Have you been diagnosed with seizure disorder or epilepsy?

Yes

No

Not sure

How often do you have seizures?

When was the last time you had a seizure?

4. Have you had a diagnostic work-up for the condition you wish to treat?

Yes

No

5. Over the last 2 weeks, have you been feeling down, depressed, or hopeless?

Yes

No

6. Do you feel anxious or nervous on a regular basis?

Yes

No

7. Have you had any recent thoughts (past month) that you would be better off dead or of hurting yourself in some way?

Yes

No

Have you ever attempted harming yourself or anyone else?

Yes

No

How long ago was this?

8. Are you under the care of a psychiatrist?

Yes

No

Who is your psychiatrist?

Please list your current psychiatric medications.

9. Do you wear thick locs or semi-permanent hairpieces?

Yes

No

Full Name:

E-mail:

Phone No:

Would you like us to contact you?

If yes, when would be a good time to contact you?

Via:

Phone Call

Email

Services

Brain Body Balance TMS
Neurology Clinic
About
Contact

Brain Body Balance TMS

Address:529 North Highland St. Memphis, TN 38122
Phone:(901) 249-2154Opens in your application

Neurology Clinic

Address:515 North Highland Street Memphis, TN 38122
Phone:901.244.7599
Email:contact.ihaneuro@gmail.comOpens in your application