COVID-19 PANDEMIC PATIENT DISCLOSURES
This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19, also known as “Coronavirus,” pandemic. A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, 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 such disclosures may impact treatment decisions. People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. These symptoms may appear 2-14 days after exposure to the virus. It is important that you disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.
1. Have you been in contact with someone who has tested positive for COVID-19 within the last 14 days?Please selectYesNo2. Have you tested positive for COVID-19 within the last 14 days? Please selectYesNo3. Have you been tested for COVID-19 and are awaiting results?Please selectYesNo4. Do you have a fever or above normal temperature?Please selectYesNo5. Have you experienced shortness of breath or had trouble breathing?Please selectYesNo6. Do you have a cough or running nose or sore throat?Please selectYesNo7. Have you recently lost or had a reduction in your sense of smell or taste?Please selectYesNo8.Have you experienced chills or repeated shaking with chills within the last 14 days?Please selectYesNo9. Do you have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?Please selectYesNo10. Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? Please selectYesNo11. Do you otherwise feel unwell?Please selectYesNoI fully understand and acknowledge the above information, risks and cautions and have disclosed to my provider any other conditions in my health history. By signing this document, I acknowledge that the answers I have provided above are true and accurate. Patient's full name *: Date: 05/05/2024
I fully understand and acknowledge the above information, risks and cautions and have disclosed to my provider any other conditions in my health history. By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Patient's full name *:
Date: 05/05/2024
