Health screening questionnaire: Date Effective: November 2nd, 2023

Please answer the following questions.

Please Note: You will be asked the same questions upon arrival to the office. If there are any changes after you send the screening form, please call our office ASAP to reschedule the appointment.

    Factors such as old age, diabetes and end-stage renal disease are generally not considered immunocompromised. Examples of being immunocompromised include: individuals undergoing cancer chemotherapy, individuals with untreated HIV infection with CD4 T lymphocyte count less than 200, individuals with a combined primary immunodeficiency disorder, individuals on prednisone medicatIon - more than 20 mg per day (or equivalent) for more than 14 days or on other immune suppressive medications.