COVID-19 Questionnaire

Patient First Name

Patient Last Name

Birth Date

COVID-19 PANDEMIC-PATIENT DISCLOSURE

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

Do you have a fever or above normal temperature?

Yes No

Have you experienced shortness of breath or had trouble breathing?

Yes No

Do you have a dry cough?

Yes No

Do you have a runny nose?

Yes No

Have you recently lost or had a reduction in your sense of smell?

Yes No

Do you have a sore throat?

Yes No

Are you in contact with someone who has tested positive for COVID-19?

Yes No

Have you tested positive for COVID-19?

Yes No

Have you been tested for COVID-19 and are awaiting results?

Yes No

Have you traveled outside the United States by air or cruise ship in the past 14 days?

Yes No

Have you traveled within the United States by air, bus or train with in the past 14 days?

Yes No

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

Form Completion

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

Signature of Patient, Parent or Guardian

Clear

Clear

Date

Form Completion

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