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COVID-19 Questionnaire

COVID 19 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 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 higher 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 a fever or above normal temperature? 
 Have you experienced shortness of breath or had trouble breathing? 
 Do you have a dry cough?  
 Do you have a runny nose? 
 Have you recently lost or had a reduction in your sense of smell? 
 Do you have a sore throat? 
 Do you have chills? 
 Do you have repeated shaking with chills? 
 Do you have muscle pain?  
 Do you have a headache? 
 Have you tested positive for COVID‐ 19?
 Have you been in contact with someone who has tested positive for COVID‐ 19?
 Have you been tested for COVID‐ 19 and are awaiting results?

Have you traveled outside Nebraska in the past 14 days? If so, where?