Transcranial Magnetic Stimulation (TMS) Safety Questionnaire

Transcranial magnetic stimulation produces a strong magnetic field, which can be dangerous for individuals with metal, electronic and mechanical implants, devices or objects. For this reason this questionnaire must be filled out prior to stimulation.

Name and surname Height cm Weight kg

Date of birth Sex Handedness




Have you ever participated in a TMS study or examination before?
Have you ever experienced any problems during the examination?
The nature of possible problems:
Have you ever undergone a heart or chest surgery?
Have you ever undergone head, ear or spinal cord surgery?
Have you ever undergone a surgery in which a metal object was implanted in your body?
If yes, describe:
Do you have any history of epileptic seizures?
Do you have any of the following:
PacemakerArtificial heart valve
Insulin pumpArtificial limbs or joints
Deep brain stimulationHearing aid or an ear implant
Electrically, magnetically or mechanically activated implant
Are you currently on any medications?
If yes, specify which:
Have you ever had a serious head injury accompanied by loss of consciousness?
If yes, describe:
Is there any chance that you might be pregnant?
Please write preffered date and time of when you would like to participate in experiment
Before submitting the questionaire, check if your answers are accurate!