Note to referrers: TMS is delivered as part of the broader clinical care coordinated by the referrer. We will report back on the patient’sprogress and any issues arising during the course of the TMS treatment.

PATIENT DETAILS

Surname *

First Name *

DOB *

Phone

Address

Acute courseMaintenance courseDVA – Gold/White DVA Number

Please specify

INDICATIONS FOR TMS

1. Indication for TMS treatment

DepressionAnxiety

2. Additional Diagnosis

OCDPTSDPain ManagementPersonality DisorderBPADOther

Please specify

3. Main reason for treatment

Minimal to no response to medicationPoor tolerability to medications (side effects/risks)Previous good response to TMSPatient preference/requestOther

Please specify

4. Previous neurostimulation

rTMSECT

rTMS - How many times

ECT - How many times

5. Has the patient adequately trialed at least 2 classes of antidepressants without satisfactory improvement?

YesNoPatient was contraindicated

6. Has the patient undertaken psychological therapy, if clinically appropriate?

YesNoNot clinically appropriate

7. Potential risks/considerations

Epilepsy/history of seizuresEye injuriesPacemaker or other implantable medical devicesCochlear implantPrevious problems with TMSNeurosurgerySuicidal thought Aggression/agitationPregnantOther

8. List current medications and dosages

9. Additional Information

REFERRING PRACTITIONER

Referrer’s Name

Provider No *

Practice Address

Contact No

Doctor’s Signature *

Draw signature|Type signatureClear

Date

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