COVID Questionnaire 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 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.Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?* Yes No Have you or anyone in your household tested positive for COVID-19 within the past 21 days or are awaiting COVID-19 test results?* Yes No Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?* Yes No Have you or anyone in your household travelled outside of New England, flown on a plane or travelled on a cruise ship in the last 21 days?* Yes No Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?* Yes No Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?* Yes No To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?* 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.Type Signature* Date* MM slash DD slash YYYY
