Health Risk Assessment

In order to limit the risk of exposure of the current COVID-19 (Coronavirus) and to ensure the safety of our patients, staff and facility, as required by the CDC, we ask all patients to fill out a risk-assessment survey prior to their scheduled appointment.
 
 *Please be notified, that you may be liable for knowingly providing or misleading information that would cause harm and or damages to others.  The purpose of this assessment is to only factor in risk factors of exposure to the COVID-19. The purpose of this assessment is not intended for the diagnosis or treatment of disease or other conditions, including COVID-19.
 

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* 1. Please fill out your contact information. This information is only shared with the Doctor.

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* 2. Have you traveled to any of the following countries in the past 14 days (Europe, China, Iran, Ireland, Malaysia, South Korea, United Kingdom including Wales, England, Scotland and Northern Ireland)?

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* 3. In the past two to four weeks, have you had any of the following: cough, sore throat, fatigue, fever, chills, and or difficulty breathing)

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* 4. In the past 30 days, have you had any contact with any individual with a laboratory dianogsis of COVID-19?

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* 5. Are you currently a healthcare worker in a U.S. health care setting?

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* 6. In the past 30 days, have any of your family members, spouse or relatives experienced any symptoms of cough, fever, fatigue, and or shortness of breath?

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* 7. In the past 30 days, have you or are you currently taking care of anyone that has any of the symptoms above and or a laboratory diagnosis of COVID-19?

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* 8. Is there any personal COVID-19 related health concerns that your doctor should know about, prior to your visit?

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* 9. Have you stayed in or in quarantine for the past 14 days ?

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