Medical University of South Carolina

Brain Stimulation Laboratory

Candidate Questionnaire

1. Please print and sign your name, indicating that you understand this information is confidential and will not be viewed by anyone other than our staff for professional purposes: X_________________________________________________(date)__________________.
2. Date of Birth:___________________ Sex_____
3. Please describe the nature of your concerns and what prompted you to contact us:___________________________________________________________________________________________________________________________________________________
4. What is your diagnosis?:_______________________________________________________
5. How long in your life have you been suffering? ___________________________________
6. What are your current medications, their doses, when did you start them and how do they work for you (if applicable): ___________________________________________________ ______________________________________________________________________________________________________________________________________________________

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7) What other medications/treatments have you tried in the past for your illness? Doses? Duration’s? Outcome? __________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8) Do you have any medical conditions? ___________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9) Have you ever experienced; seizure, heart attack, stroke, brain surgery, recent head trauma?

If yes, please explain: ___________________________________________________________