Infectious Disease Questionnaire Thank you for your continued trust! If you have been exposed to a communicable disease, you may spread the disease to the staff or other patients/parents in the practice. Therefore, prior to each appointment we will be asking the following questions to reduce the chances of transmission: Have you been outside of the city or state in the last two weeks? Select Yes Or NoYesNoIf yes, When and Where?Has guardian tested positive for or been diagnosed as having COVID-19, Influenza, or any other communicable disease? Select Yes Or NoYesNoGuardian vaccinated for Covid-19? Select Yes Or NoYesNoGuardian vaccinated for influenza? Select Yes Or NoYesNoHas Patient tested positive for or been diagnosed as having COVID-19, Influenza, or any other communicable disease? Select Yes Or NoYesNoPatient vaccinated for Covid-19?Select Yes Or NoYesNoPatient vaccinated for influenza?Select Yes Or NoYesNoDo you, your child, or others accompanying you or other recent acquaintances have: A fever in the last week, or today? (defined as 99.6 or above)Select Yes Or NoYesNoShortness of breath and/or trouble breathing? Select Yes Or NoYesNoA cough? Select Yes Or NoYesNoPersistent pain, pressure, or tightness in the chest?Select Yes Or NoYesNoI understand that if the answer to any of these questions is yes, I will be asked to reschedule, or the appointment may be conducted online to reduce transmission risks. As with the transmission of any communicable disease like the cold or flu, you may be exposed to COVID-19, at any time or any place. Be assured I have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. Despite the careful attention to sterilization, disinfection and use of personal barriers, there is still a chance that you could be exposed to an illness in the office, just as you may at other places you travel. “Social distancing” has reduced the transmission, however, due to the nature of this therapy, it is not always possible to maintain a six-foot distance between the therapist and the client/patient. Do you accept the risk and consent to therapy?Select Yes Or NoYesNoTyping your name will act as a signature using online formDate PhoneSubmit
