{"id":7,"date":"2020-05-29T12:55:32","date_gmt":"2020-05-29T10:55:32","guid":{"rendered":"https:\/\/parodontistemontreal.com\/protocole\/?page_id=7"},"modified":"2020-05-29T08:42:58","modified_gmt":"2020-05-29T12:42:58","slug":"questionnaire-covid-19-fr","status":"publish","type":"page","link":"https:\/\/parodontistemontreal.com\/protocole\/","title":{"rendered":"Questionnaire COVID-19 fr"},"content":{"rendered":"<p><span style=\"font-size: 24px; color: #cc0000;\">Formulaire de de\u0301pistage du patient\/accompagnateur<\/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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var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/protocole\/wp-json\/wp\/v2\/pages\/7' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_34\" 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_3_34'>Alerte<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_3_34' type='text' value='* SYMPT\u00d4MES *' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_36\" 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_3_36'>Go<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_3_36' type='text' value='* Ok *' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_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_3_33'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_3_33' type='text' value='15 mai 2026 22h33' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_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_3_11'>Nom de la personne d\u00e9pist\u00e9e<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_3_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_37\" 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' >Ce formulaire est rempli :<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_3_37'>\n\t\t\t<li class='gchoice gchoice_3_37_0'>\n\t\t\t\t<input name='input_37' type='radio' value='Pre-op'  id='choice_3_37_0'    \/>\n\t\t\t\t<label for='choice_3_37_0' id='label_3_37_0' class='gform-field-label gform-field-label--type-inline'>\u00c0 la prise du rendez-vous (Pr\u00e9-op)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_37_1'>\n\t\t\t\t<input name='input_37' type='radio' value='Op'  id='choice_3_37_1'    \/>\n\t\t\t\t<label for='choice_3_37_1' id='label_3_37_1' class='gform-field-label gform-field-label--type-inline'>Au moment du rendez-vous (Op)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_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' >Veuillez indiquer si le nom ci-dessus correspond au formulaire de d\u00e9pistage du patient ou de l\u2019accompagnateur:<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_3_13'>\n\t\t\t<li class='gchoice gchoice_3_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Patient'  id='choice_3_13_0'    \/>\n\t\t\t\t<label for='choice_3_13_0' id='label_3_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_3_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Accompagnateur'  id='choice_3_13_1'    \/>\n\t\t\t\t<label for='choice_3_13_1' id='label_3_13_1' class='gform-field-label gform-field-label--type-inline'>Accompagnateur<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_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_3_8'>Nom du 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_3_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_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- Devez-vous \u00eatre en isolement en raison de la 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_3_15'>\n\t\t\t<li class='gchoice gchoice_3_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Oui'  id='choice_3_15_0'    \/>\n\t\t\t\t<label for='choice_3_15_0' id='label_3_15_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='Non'  id='choice_3_15_1'    \/>\n\t\t\t\t<label for='choice_3_15_1' id='label_3_15_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_38\" class=\"gfield gfield--type-html gfield_html 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>* Situations d'isolement requis: *<\/strong><br>\n\u2022 Vous avez obtenu un r\u00e9sultat de test positif<br>\n\u2022 Vous avez \u00e9t\u00e9 en contact avec un cas<br>\n\u2022 Vous pr\u00e9sentez des sympt\u00f4mes de la COVID-19\/sympt\u00f4mes grippaux<br>\n\u2022 Vous \u00eates de retour de voyage \u00e0 l\u2019\u00e9tranger.<\/div><\/li><li id=\"field_3_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- \u00cates-vous dans la p\u00e9riode entre 5 et 10 jours suivant votre isolement de 5 jours \u00e0 la maison en raison de la 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_3_16'>\n\t\t\t<li class='gchoice gchoice_3_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Oui'  id='choice_3_16_0'    \/>\n\t\t\t\t<label for='choice_3_16_0' id='label_3_16_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='Non'  id='choice_3_16_1'    \/>\n\t\t\t\t<label for='choice_3_16_1' id='label_3_16_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_2\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below 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