Table 1 Pre-screen form
Date of assessment: | ___ ___ / ___ ___ / ___ ___ ___ ___ (mm/dd/yyyy) | |
|---|---|---|
1. | Referral source: | ☐ Flyer ☐ Public transit ad ☐ Social media ☐ Clinicaltrials.gov ☐ Word of mouth ☐ Radio ad ☐ Craigslist ☐ Other ☐ Newspaper ad ☐ TV ad ☐ Clinical referral |
a. If “Other”, specify: | _____________________________________________________________ | |
2. | Was the participant eligible from Pre- Screen? | ☐ No ☐ Yes |
a. If “No”, reason not eligible? (select all that apply) | ☐ Less than 18 years of age or greater than 65 years of age ☐ Has not used cocaine or methamphetamine on at least 10 of the last 30 days ☐ Did not express interest in decreasing stimulant use ☐ Currently engaged in formal treatment for stimulant use disorder ☐ Currently pregnant ☐ Unwilling to use effective birth control during study ☐ Has previously received TMS in a clinical setting ☐ Has serious medical problem that would preclude safe or consistent participation in the study ☐ History of unprovoked seizure (lifetime) or any seizure in last 6 months ☐ History of brain lesion(s) and/or tumor(s) ☐ Current moderate or severe SUD, other than CcUD or MtUD ☐ Currently prescribed anticonvulsants or benzodiazepines, but not on stable dose for at least 4 weeks ☐ Suicidal or homicidal ideation ☐ Is a prisoner or in police custody ☐ Expected to be prisoner/in custody soon ☐ Metal implants or non-removable metal objects above the waist ☐ Current/lifetime history of mania or hypomania ☐ Previously randomized as a participant in the study ☐ Planned admission to a residential treatment or other formal SUD treatment program ☐ No longer interested in the study ☐ Lives too far away/transportation issues ☐ Other | |
l. If “Other”, specify: | ||
3. | If eligible, was the participant scheduled for a screening visit? | ☐ No ☐ Yes |
a. If “No”, reason not scheduled? | ☐ No longer interested ☐ Other | |
l. If “Other”, specify: | _____________________________________________________________ | |
Comments: ________________________________________________________________________________________________________________________________ | ||