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, 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 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.

Patient Name

Date of Birth

Phone Number

Have you tested positive for COVID-19 within the last 14 days?

Yes

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

Yes

Do you have a fever or above normal temperature of 100.4 F or higher?

Yes

Have you taken any fever-reducing medications, including: ibuprofen (Advil, Motrin or other), acetaminophen (Tylenol or other), naproxen (Aleve or other) or aspirin in the last 14 days and, if yes, for what reason?

Yes

Please Specify Here

Have you experienced shortness of breath or had trouble breathing?

Yes

Do you have a dry cough?

Yes

Do you have a runny nose?

Yes

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

Yes

Do you have a sore throat?

Yes

Have you experienced chills or repeated shaking with chills?

Yes

Do you have muscle pain?

Yes

Do you have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes

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

Yes

Do you otherwise feel unwell?

Yes

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 that may result in a compromised immune system.

By signing this document, I acknowledge the answers I have provided above are true and accurate.

Date Signed

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself or the entity I am authorized to represent.