BrainsWay Smoking Addiction Treatment

Deep TMS H4-Coil

Treatment Forms

Below you will find four forms that should be completed when administering a BrainsWay Deep TMS treatment course for Smoking Addiction. 

These forms ensure that the proper treatment protocol is being conducted and that key treatment data is collected.

  • Patient Intake Form
  • Treatment Data Form
  • Early Dropout Form
  • Patient Follow-Up Form

A receipt of each form will be sent to the clinic email address provided in the form.  Should you have any questions, please reach out to BrainsWay at DeepTMS@brainsway.com or 844-386-7001.

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Patient Intake

Please complete the following form prior to the patient's first Deep TMS treatment session.  The form includes Smoking History, Motivation to Quit, and Smoking Triggers.

Patient Intake Form

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Patient Treatment

Please complete the following form during each treatment session.  The form includes Provocation and Counseling materials, as well as Craving VAS scores.

Treatment Data Form

Early Dropout

Please complete the following form in the event that a patient fails to complete all 18 TMS treatment sessions.  The form documents the patient's reason for dropout.

Early Dropout Form

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Patient Follow-Up

Please complete the following form each time a patient who successfully achieved their quitting smoking goal after the Deep TMS treatment course follows up with the clinic to report progress.

Patients must visit the clinic in order to record the relevant required data on continued abstinence or relapse.

Patient Follow-Up Form