Risk Assessment of Exposure

Location*

Patient Name*

DOB*

For the Safety of our patients and staff, please answer the following questions:

Have you received a COVID -19 Vaccine?*

YesNo

If yes, date of final vaccine

Date

Have you been tested positive for COVID-19?*

YesNo

If yes, date of test

Date

Are you currently awaiting the results of a COVID 19 Test?*

YesNo

If yes, date of test

Date

Have you had close contact with an individual diagnosed with COVID 19 or with symptoms?*

YesNo

Have you been advised to self quarantine?*

YesNo

Have you had any personal contact Outside of your home?*

YesNo

If yes, check all that pertain

Within the last 4 weeks, have you experienced any of the following symptoms?

Cough*

YesNo

Shortness of breath or difficulty breathing*

YesNo

Fever*

YesNo

Chills*

YesNo

Repeated shaking with chills*

YesNo

Generalized Muscle Pain*

YesNo

New Headache*

YesNo

Sore Throat*

YesNo

New loss of taste or smell*

YesNo

Prior to entering the waiting room we ask that you wear a face mask. In addition, we ask that you use hand sanitizer provided outside the office or at the front desk before checking in with the medical staff.

To verify the absence of fever a staff member will take your temperature. (temperature above 100F or 37.7°C

Once the above questions have been reviewed and temperature taken, the staff member will provide you the status of your appointment, appointment status could be to continue as scheduled or to reschedule.

I understand that RAC has the right to reschedule my appointment due to high risk factors that may expose its staff and other members in the facility.

Signature*

Date*

Date