{"id":29,"date":"2020-05-29T08:46:04","date_gmt":"2020-05-29T12:46:04","guid":{"rendered":"https:\/\/parodontistemontreal.com\/protocole\/?page_id=29"},"modified":"2020-05-29T08:46:07","modified_gmt":"2020-05-29T12:46:07","slug":"questionnaire-covid-19-en","status":"publish","type":"page","link":"https:\/\/parodontistemontreal.com\/protocole\/questionnaire-covid-19-en\/","title":{"rendered":"Questionnaire COVID-19 en"},"content":{"rendered":"<p><span style=\"font-size: 24px; color: #cc0000;\">Patient\/Attendant Screening Questionnaire<\/span><br \/>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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formulaire.<\/span><\/div><label class='gfield_label gform-field-label' for='input_8_34'>Alerte<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_8_34' type='text' value='* SYMPT\u00d4MES *' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_35\" class=\"gfield gfield--type-text rouge field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.<\/span><\/div><label class='gfield_label gform-field-label' for='input_8_35'>Go<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_8_35' type='text' value='* Ok *' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_33\" class=\"gfield gfield--type-text gf_readonly field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_33'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_8_33' type='text' value='12 avril 2026 07h49' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_11\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_11'>Name of the person being screened<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_8_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >This form is fill :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_36'>\n\t\t\t<li class='gchoice gchoice_8_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='Pre-Op'  id='choice_8_36_0'    \/>\n\t\t\t\t<label for='choice_8_36_0' id='label_8_36_0' class='gform-field-label gform-field-label--type-inline'>At the appointment scheduling (Pre-Op)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='Op'  id='choice_8_36_1'    \/>\n\t\t\t\t<label for='choice_8_36_1' id='label_8_36_1' class='gform-field-label gform-field-label--type-inline'>Just before the operation (Op)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Please indicate if the name below corresponds to the patients questionnaire or the person accompanying the patient?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_13'>\n\t\t\t<li class='gchoice gchoice_8_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Patient'  id='choice_8_13_0'    \/>\n\t\t\t\t<label for='choice_8_13_0' id='label_8_13_0' class='gform-field-label gform-field-label--type-inline'>Patient<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Attendant'  id='choice_8_13_1'    \/>\n\t\t\t\t<label for='choice_8_13_1' id='label_8_13_1' class='gform-field-label gform-field-label--type-inline'>Attendant<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_8\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_8'>If attendant name of patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_8_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_15\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1- Do you need to be in isolation due to COVID-19?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_15'>\n\t\t\t<li class='gchoice gchoice_8_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Yes'  id='choice_8_15_0'    \/>\n\t\t\t\t<label for='choice_8_15_0' id='label_8_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='No'  id='choice_8_15_1'    \/>\n\t\t\t\t<label for='choice_8_15_1' id='label_8_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_25\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#fbd9d9;padding:5px;border:solid 1px #cc0000\"><strong>* Required isolation situations: *<\/strong><br>\n\u2022 You tested positive<br>\n\u2022 You have been in contact with a case<br>\n\u2022 You have symptoms of COVID-19\/flu<br>\n\u2022 You are back from a trip abroad.\n<\/div><\/li><li id=\"field_8_16\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2- Are you in the 5-10 day period following your isolation of 5 days at home due to COVID-19?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_16'>\n\t\t\t<li class='gchoice gchoice_8_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Yes'  id='choice_8_16_0'    \/>\n\t\t\t\t<label for='choice_8_16_0' id='label_8_16_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='No'  id='choice_8_16_1'    \/>\n\t\t\t\t<label for='choice_8_16_1' id='label_8_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_2\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label 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