Healthcare Exposure Update Questionnaire

Healthcare Exposure Update Questionnaire

Patient Information

Patient Name:   Date of Birth:

Phone:   Email:

Insurance & Employment

Policy Number:   Group Number:

Exposure Details

Date of suspected exposure:

High-risk close contact (within 6 feet, prolonged)
Household contact
Patient care without recommended PPE
Community exposure (public setting)
Other:

Symptoms & Testing

Fever or chills   Cough   Shortness of breath
Sore throat   Loss of smell/taste   No current symptoms
Other:

Symptom onset date:

Have you been tested for the agent since exposure?   Yes No

Vaccination & Medical History

Diabetes Chronic lung disease Cardiovascular disease
Immunocompromised None of the above
Other chronic conditions:

Household & Contacts

Yes No   If no, explain:

Authorization & Privacy Acknowledgment

I certify that the information provided in this Healthcare Exposure Update Questionnaire is accurate and complete to the best of my knowledge. I authorize the release and disclosure of relevant medical and exposure information to the facility's infection prevention team, occupational health, and public health authorities for the purposes of exposure assessment, contact tracing, clinical evaluation, and any required reporting. I understand that information disclosed under this authorization may include medical history, test results, vaccination status, and symptom information.

I understand that I may withdraw this authorization at any time by providing written notice, except to the extent actions have already been taken in reliance upon this authorization. Unless revoked sooner, this authorization expires on the date indicated below.

I acknowledge receipt of the facility's privacy practices related to the use and disclosure of my health information in connection with exposure management, and I consent to the limited uses and disclosures described above.

I acknowledge and consent to the uses and disclosures stated above.

Additional Information

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