COVID-19 Questionnaire

COVID-19 required questionnaire

We are closely monitoring and, in some cases, restricting access at this location in light of the ongoing COVID-19 issue.

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 weakened 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 or have you had a fever or above normal temperature in the last 14 days?
YesNo

Have you experienced shortness of breath or had trouble breathing?
YesNo

Do you have a dry cough?
YesNo

Do you have a runny nose or sore throat?
YesNo

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

Is your age over 60?
YesNo

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?
YesNo

Have you been in contact with someone who has tested positive for COVID -19?
YesNo

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

Have you tested positive for COVID-19?
YesNo

When did you test positive?

Have you traveled outside of Nebraska in the past 14 days?
YesNo

Have you been asked to self-quarantine?
YesNo

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.

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