COVID-19 Screening 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.

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First Name *
Last Name *
Date of Birth *
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DD
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YYYY
Phone Number *
Do you have a fever or abnormal temperature above 98.6F? *
Have you experienced shortness of breath or had trouble breathing? *
Do you have a dry cough or runny nose? *
Have you experienced loss of taste or smell? *
Have you come in contact with someone who is COVID-19 positive? *
Have you been tested for COVID-19 and are awaiting results? *
Have you traveled outside of the USA in the past 14 days? *
If you have tested positive for COVID-19 have you been 14 days symptom free and had two negative tests?
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Please indicate if you have a compromised immune system with any of the following co-morbidities with COVID-19
By signing this document, I acknowledge that the answers I have provided above are true and accurate. *
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