Immunosuppressed Patient Screening Form
Use this form to share basic contact details, screening reason, current immune-related treatments or conditions, and any recent symptoms or exposures that may affect screening.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Screening Details
Main reason for screening
*
Current immune-suppressing treatments
*
Chemotherapy
Transplant-related medication
Steroids
Biologic therapy
None
Other immune-suppressing treatment
If other, please specify
Current Health Status
Recent symptoms or exposure concerns
*
Fever
Cough
Shortness of breath
Sore throat
Fatigue
Known recent infection
Recent close exposure to someone with an infectious illness
None of the above
Recent transplant, active cancer treatment, or other immune-compromising diagnosis
*
Yes
No
Additional notes
Submit
Should be Empty: