Questionnaire COVID-19 en – Parodontiste Montréal

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Date

Name of the person being screened*

This form is fill :*

At the appointment scheduling (Pre-Op)
Just before the operation (Op)

Please indicate if the name below corresponds to the patients questionnaire or the person accompanying the patient?*

Patient
Attendant

If attendant name of patient*

1- Do you need to be in isolation due to COVID-19?*

Yes
No

* Required isolation situations: *
• You tested positive
• You have been in contact with a case
• You have symptoms of COVID-19/flu
• You are back from a trip abroad.

2- Are you in the 5-10 day period following your isolation of 5 days at home due to COVID-19?*

Yes
No

Signature of the person who filled out the questionnaire*