COVID-19 Patient Screen and Disclosure Form COVID-19 PANDEMIC - PATIENT SCREEN/DISCLOSUREThis patient disclosure form seeks information from you that we must consider before making treatment decisions during the COVID-19 pandemic.A weakened or compromised immune system (which may be due to underlying conditions like cancer, diabetes, asthma, and COPD; treatments like radiation, chemotherapy, and immunosuppressive drugs; and any prior or current disease or medical condition), can put you at greater risk for contracting COVlD-19. Please disclose to us any condition or treatment/medication that weakens or 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 COVID-19.Patient Name*Current Temperature*Do you have a fever or above normal temperature?*YesNoHave you experienced shortness of breath or had trouble breathing?*YesNoDo you have a dry cough?*YesNoDo you have a runny nose?*YesNoHave you recently lost or had a reduction in your sense of smell or taste?*YesNoDo you have a sore throat?*YesNoHave you been in contact with someone who has tested positive for COVID-19?*YesNoHave you tested positive for COVID-19?*YesNoHave you been tested for COVID-19 and are awaiting results?*YesNoHave you traveled outside the United States in the past 14 days?*YesNoHave you traveled within the United States by air, bus or train within the past 14 days?*YesNoI fully understand and acknowledge the above information, risks and cautions regarding a weakened or compromised immune system and have disclosed to my provider any conditions in my health history which may result in a weakened or compromised immune system.By signing this document, I acknowledge that the answers l have provided above are true and accurate.Signature*Date* Date Format: MM slash DD slash YYYY Witness Signature*Witness Date* Date Format: MM slash DD slash YYYY
