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?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 or sore throat?Yes No
Have you recently lost or had a reduction in you sense of smell?Yes No
Is your age over 60?Yes No
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?Yes No
Have you been in contact with someone who has tested positive for COVID -19?Yes No
Have you been tested for COVID-19 and are awaiting results?Yes No
Have you tested positive for COVID-19?Yes No
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When did you test positive?
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Have you traveled outside of Nebraska in the past 14 days?Yes No
Have you been asked to self-quarantine?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. By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Signature:
