Form

COVID-19 SCREENING FORM

This patient screening 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.

First Name

Last Name

Date Of Birth

Do you/they have fever or have you/they felt hot or feverish recently?

Are you/they having shortness of breath, other difficulties breathing, or cough? (Not including those with chronic coughs, or lung diseases that may cause coughing)

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Have you/they experienced recent loss of taste or smell?

In the last 10 days, have you/they been in contact with any confirmed COVID-19 positive patients? (Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment). If yes, please call our office.

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Additional Comments?

Comments

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/Legal Guardian Signature

Date

Relationship to Patient