- When coughing or sneezing, cover your nose and/or mouth
- Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use.
- Wash your hands with soap and water or with sanitizing hand-gel after you have had contact with contaminated tissues or respiratory secretions, etc.
To ensure that our patients are treated in an environment that promotes health and well being, and in accordance with OSHA requirements for providing a safe and healthful workplace, patients suffering from aerosol transmissible illnesses such as mumps, chickenpox, measles, new types of the flu, TB, or other illnesses that may be spread by droplets or by airborne transmission, should make our office aware of their condition.
Please complete and return the questionnaire below.
Are you suffering from any of the following signs or symptoms of aerosol transmissible illnesses?
1) Do you have a transmissible respiratory illness other than the common cold or seasonal influenza?____Yes No
2) Have you had a cough for more than three weeks that is not explained by non-infectious conditions? ____Yes No
3) Have you had coughing fits that interfere with eating, drinking or breathing? ___Yes No
4) In addition to coughing, have you experienced any of the following?
- unexplained weight loss (more than 5 pounds) ____Yes No
- night sweats ____Yes No
- fever ____Yes No
- chronic fatigue or malaise ____Yes No
- coughing up blood ____Yes No
5) Have you had a fever, headache, muscle aches, tiredness, and poor appetite, followed by painful, swollen salivary glands on one or both sides of the face under the jaw? ___Yes No
6) Have you had fever, headache, stiff neck, chills, cough, runny nose, or watery eyes associated with the onset of an unexplained rash (diffuse rash or blister-type skin rash), or possibly mental status changes? ___Yes No
7) Do you show signs and symptoms of a flu-like illness during March through October, (the months outside of the typical period for seasonal influenza in the United States), or do you show the signs and symptoms of flu for longer than two weeks at any time during the year? These signs and symptoms generally include combinations of the following;:
8)Have you been exposed to anyone with an infectious aerosol transmissible illness (see below for list of such illnesses) other than seasonal influenza? Yes No (If yes, please indicate below)
List of Illnesses That Should Be Reported:
- Avian flu, novel flu, swine flu, or any other type of flu other than seasonal flu
- Tuberculosis or TB
- Haemophilus influenzae type B or Hib
- Pertussis or whooping cough
- Epstein-Barr virus
- Scarlet fever
List any other new types of infectious diseases or illness of which you may have been exposed
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