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**RESPIRATORY SCREENING ‐ PATIENT DISCLOSURES

Please read and answer questions below

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of Respiratory virus(es).

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 Respiratory virus(es). 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 Respiratory virus(es), including RSV, Influenza, Measles, COVID‐19, etc. or whether you have experienced any signs or symptoms associated with the Respiratory virus(es).

Do you have a fever or above normal temperature?

Have you experienced shortness of breath or had trouble breathing through your nose or mouth?

Do you have a dry cough?

Do you have a runny nose?

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

Do you have a sore throat?

Have you been in contact with someone who has tested positive for Influenza, RSV, Measles, COVID‐19, etc.?

Have you been tested for Influenza, Strep Throat, RSV, Measles, COVID‐19, etc. and are awaiting results?

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

Are you experiencing any loss of taste?

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.

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

Patient's First Name

Patient's Last Name

Relationship to Patient

Date

Signature