QUESTIONNAIRES

Questionnaires

EMG QUESTIONNAIRE

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Questionnaires

TMS QUESTIONNAIRE

Please answer as completely and honestly as you can to allow us to prepare an accurate report.

TMS Questionnaire

1. Please enter your initials: *

2. DOB: *

3. Age: *

4. Writing Hand: *

5. Working as/Retired from: *

6. Email: *

7. Phone Number: *

8. Weight: *

9. Height: *

10. Medication List (Include drug name, mg in tablet, number of pills, times per day) For example: Costalot 10 mg tabs, 2 tabs, three times/day: *

11. Surgeries: *

12. Medical History/Problems: *

13. Drug Allergies: *

14. Do you smoke? *

Yes

15. Do you drink alcohol? *

Yes

16. Do you use any illicit drugs? *

Yes

How many cigarettes/day:

How many drinks/week:

Please list:

17. Family history of neurological disorders: *

18. What is your level of education? *

19. What condition are you seeking treatment for today? *

20. What have you tried for your condition, if anything? Any benefit? *

21. Have you had any side effects with your current or prior treatments? If so, what are/were they? *

22. What made you consider TMS as a treatment now? *

Please indicate if you have any of the following:

Aneurysm clips or coils *

Yes

Wearable cardioverter defibrillator *

Yes

Cardiac pacemaker or wires *

Yes

Implanted insulin pump *

Yes

Internal cardioverter defibrillator (ICD) *

Yes

Programmable shunt or valve *

Yes

Carotid or cerebral stents *

Yes

Hearing aid *

Yes

Deep brain stimulator *

Yes

Metallic devices implanted in your head *

Yes

Cervical fixation devices *

Yes

Surgical clips, staples, or sutures *

Yes

Dental implants *

Yes

VeriChip microtransponder *

Yes

Wearable monitor (e.g., heart monitor) *

Yes

Cochlear implant/ear implant *

Yes

CSF (cerebrospinal fluid) shunt *

Yes

Bone growth stimulator *

Yes

Eye implants *

Yes

Wearable infusion pump *

Yes

Cardiac stents, filters, or metallic valves *

Yes

Radioactive seeds *

Yes

Tattoos *

Yes

Portable glucose monitor *

Yes

Vagus nerve stimulator (VNS) *

Yes

Tracheostomy *

Yes

Blood vessel coil *

Yes

Medication patch/nicotine patch *

Yes

Shrapnel, bullets, pellets, BBs, or other metal fragments *

Yes

Other implanted metal or device. If yes, please specify: *

Yes

Specify: *

Have you ever been a machine welder, or metal worker? *

Yes

Have you ever had a facial injury from metal and/or metal removed from your eyes? *

Yes

Are you pregnant? *

Yes

Last menstrual period, if applicable:

Have you ever had a seizure or have a known seizure disorder? *

Yes

Have you ever had complications from an MRI? *

Yes

Have you been diagnosed with increased intracranial pressure (due to tumor or other known cause)? *

Yes

Have you had significant brain or head injury over the last year and/or intracerebral hemorrhage in the past? *

Yes

Name of person completing this form: *

Date *

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Questionnaires

INDEPENDENT MEDICAL QUESTIONNAIRE

Please answer as completely and honestly as you can to allow us to prepare an accurate report. PLEASE DO NOT COMPLETE THIS FORM IF YOU ARE BEING SEEN FOR A TMS OR EMG CONSULTATION.

IME Questionnaire

01. Please provide the initials of your first and last name *

02. What is your date of birth? *

03. Are you? *

Right Handed

Left Handed

Ambidextrous

04. What is your height? *

05. What is your weight? *

06. What is the date of your injury? *

07. Have you ever had any previous problems or injuries, including any other work-related, recreational, or motor vehicle injuries? *

Yes

Not Sure

If yes, please describe:

08. Have you ever had any difficulties prior to the date of your injury that were similar to those you are now experiencing? *

Yes

Not Sure

If yes, please describe:

09. Please describe how your condition/injury occurred *

10. What problems did you have at that time? *

11. What did you do following the condition/injury? *

12. Briefly describe what has occurred since that time to this date: *

13. What is your greatest concern at this time? If you are not having difficulty with pain, proceed to question 18.

14. Where is your pain located?

15. How would you describe your pain?

16. What makes your pain worse?

17. What makes your pain better?

18. How frequent is your pain?

Constant (present 3/4 to all of the time)

Frequent (present 1/2 to 3/4 of the time)

Occasional (present 1/4 to 1/2 of the time)

Intermittent (present less than 1/2 of the time)

19. On a scale from 0 (no pain) to 10 (excruciating pain)

a. What number would you put on your pain at this time?

b. During the past month, what has it averaged?

c. During the past month, what is the highest it has been?

d. During the past month, what is the lowest it has been?

20. Are you having any other difficulties? *

Yes

Not Sure

If yes, please describe these difficulties in detail:

21. Are any tasks difficult for you to perform? *

Yes

Not Sure

If yes, please describe the tasks that are most difficult for you:

If your injury is not work-related, please proceed to question 28.

22. Who were you employed by when you were injured?

23. How long had you been working there?

24. What was your job?

25. What did this job involve?

26. What type of work have you performed previously?

27. What is your level of education?

28. Are you working now? *

Yes

Please describe:

29. Has your doctor, or anyone, prescribed any work restrictions? *

Yes

If yes, please describe these restrictions:

30. Where do you live? *

31. Who lives with you? *

32. Please describe your typical day *

33. Are you involved in any work activities or any significant recreational pursuits? *

Yes

Not sure

If yes, please describe:

34. Do you smoke? *

Yes, in the past, but I quit

Yes

If yes, how many packs per day?

35. How many alcoholic beverages do you have per week? *

36. Have you had any medical hospitalizations? *

Yes

Not sure

If yes, please describe:

37. Have you had any operations? *

Yes

Not sure

If yes, please describe:

38. Are you taking any prescribed medications? *

Yes

Not sure

If yes, please list:

39. Are you allergic to any medications? *

Yes

Not sure

If yes, please describe:

40. Have you had any other medical problems? *

Yes

Not sure

If yes, please describe:

41. Do any diseases run in your family? *

Yes

Not sure

If yes, please describe:

For each of the 7 categories of life activity listed, please circle the number on the scale that describes the level of disability you typically experience. A score of 0 means no disability at all, and a score of 10 signifies that all of the activities in which you would normally be involved have been totally disrupted or prevented by your pain.

1. Family/Home Responsibilities: This category refers to activities of the home or family. It includes chores or duties performed around the house (e.g. yard work) and errands or favors for other family members (e.g. driving the children to school). *

2. Recreation: This disability includes hobbies, sports, and other similar leisure time activities. *

3. Social Activity: This category refers to activities, which involve participation with friends and acquaintances other than family members. It includes parties, theater, concerts, dining out, and other social functions. *

4. Occupation: This category refers to activities that are part of or directly related to one’s job. This includes non-paying jobs as well, such as that of a housewife or volunteer. *

5. Sexual Behavior: This category refers to the frequency and quality of one’s sex life. *

6. Self Care: This category includes activities, which involve personal maintenance and independent daily living (e.g. taking a shower, driving, getting dressed, etc.) *

7. Life-Support Activities: This category refers to basic life supporting behaviours such as eating, sleeping and breathing. *

Please provide any other comments that may assist us in understanding your situation: Thanks for your assistance. At the time of the visit we will review this information in further detail.

I understand that I am being seen for an independent medical evaluation and no treating physician/patient relationship is established. I understand that the information I discuss will be included in a report that is prepared for the requesting client. I consent to this report being sent to this client and to participating in the assessment. I agree to advise the physician immediately if I experience any difficulties during the examination.

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