A Mindful Path to Mental Health -Office Visit

You must complete this screening questionnaire before each visit to our office on the day of your visit. Please confirm today's date and the date of your appointment.

Appointment Date

Reason for today's visit

Office visit with Dr. Bonilla TMS appointment I am accompanying a patient Other (please specify on comments)

Comments

Name

Phone number

Patient's name (if accompanying a patient)

Symptom History

Have you experienced any of the following symptoms in the past week?

Fatigue

Yes No

Muscle or body aches

Yes No

Congestion or runny nose

Yes No

Cough

Yes No

Shortness of breath or difficulty breathing

Yes No

Headache

Yes No

Sore throat

Yes No

New loss of taste or smell

Yes No

Diarrhea

Yes No

Nausea or vomiting

Yes No

Have you experienced any of the following symptoms in the last 74 hours?

Fever or chills

Yes No

Severe weakness

Yes No

Fast or shallow breathing

Yes No

Clinical History Update

In the past 14 days have you had contact with anyone who has been diagnosed with COVID-19?

Yes No

In the past 14 days have you had contact with anyone who is suspected to have COVID-19 or who is waiting to get COVID-19 testing results?

Yes No

Has anyone you live with been sick in the last 14 days?

Yes No

Did your headache happen since/after the last TMS treatment?

Yes No

Any alcohol consumption since the last treatment?

Yes No

How much?

Any recreational drug use since the last treatment?

Yes No

Please elaborate

Any changes in caffeine consumption?

Yes No

Please elaborate

Any dietary changes?

Yes No

Please elaborate

Any change in sleep patterns?

Yes No

Please elaborate

Are there any changes in medication?

Yes No

Please elaborate

Initials

Today's date

Thank you for helping us keep all our staff and patients safe by taking the time to complete this questionnaire. If you answered yes to any of the questions stay home or in your car until you are given further direction by a staff member, someone will call you when we receive this form or you can contact us at (916) 587-8038

Your information will be encrypted.

A Mindful Path to Mental Health -Office Visit

Symptom History

Clinical History Update

A Mindful Path To Mental Health