{"id":1769,"date":"2020-08-03T00:51:02","date_gmt":"2020-08-03T04:51:02","guid":{"rendered":"https:\/\/cliniquemaxillo.com\/?page_id=1769"},"modified":"2020-08-03T10:49:06","modified_gmt":"2020-08-03T14:49:06","slug":"questionnaire-covid-19-staff","status":"publish","type":"page","link":"https:\/\/cliniquemaxillo.com\/en\/protocole\/questionnaire-covid-19-staff\/","title":{"rendered":"Questionnaire COVID-19 Staff"},"content":{"rendered":"<div class=\"text-holder\"><span style=\"font-size: 24px; color: #22b3a9;\">Patient\/Attendant Screening Questionnaire &#8211; ADMINISTRATION<\/span><br \/>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_12' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_12'  action='\/en\/wp-json\/wp\/v2\/pages\/1769\/' data-formid='12' novalidate> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><ul id='gform_fields_12' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_12_34\" class=\"gfield gfield--type-text rouge field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_12_34\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_12_34'>Alerte<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_12_34' type='text' value='* SYMPT\u00d4MES *' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_12_35\" class=\"gfield gfield--type-text rouge field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_12_35\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_12_35'>Go<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_12_35' type='text' value='* Ok *' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_12_33\" class=\"gfield gfield--type-text gf_readonly field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_33\" ><label class='gfield_label gform-field-label' for='input_12_33'>Date - Day of appointment<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_12_33' type='text' value='28 avril 2024 17h02' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_12_11\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_11\" ><label class='gfield_label gform-field-label' for='input_12_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_12_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_12_13\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_13\" ><label class='gfield_label gform-field-label' >Clinic<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_12_13'>\n\t\t\t<li class='gchoice gchoice_12_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Lachine'  id='choice_12_13_0'    \/>\n\t\t\t\t<label for='choice_12_13_0' id='label_12_13_0' class='gform-field-label gform-field-label--type-inline'>Lachine<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_12_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Ste-Catherine'  id='choice_12_13_1'    \/>\n\t\t\t\t<label for='choice_12_13_1' id='label_12_13_1' class='gform-field-label gform-field-label--type-inline'>Ste-Catherine<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_15\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_15\" ><label class='gfield_label gform-field-label' >1- Have you had a positive COVID-19 screening test in the last 21 days or are you awaiting a screening test result?<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_12_15'>\n\t\t\t<li class='gchoice gchoice_12_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Yes'  id='choice_12_15_0'    \/>\n\t\t\t\t<label for='choice_12_15_0' id='label_12_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_12_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='No'  id='choice_12_15_1'    \/>\n\t\t\t\t<label for='choice_12_15_1' id='label_12_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_25\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_25\" ><div style=\"background-color:#22b3a9;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">Have you experienced any of the following symptoms<\/div><\/li><li id=\"field_12_16\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_16\" ><label class='gfield_label gform-field-label' >2- Fever (over 38 \u00b0C or 100,4 \u00b0F)?<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_12_16'>\n\t\t\t<li class='gchoice gchoice_12_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Yes'  id='choice_12_16_0'    \/>\n\t\t\t\t<label for='choice_12_16_0' id='label_12_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_12_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='No'  id='choice_12_16_1'    \/>\n\t\t\t\t<label for='choice_12_16_1' id='label_12_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_17\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_17\" ><label class='gfield_label gform-field-label' >3- Recent or chronic cough that has gotten worse?<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_12_17'>\n\t\t\t<li class='gchoice gchoice_12_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Yes'  id='choice_12_17_0'    \/>\n\t\t\t\t<label for='choice_12_17_0' id='label_12_17_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_12_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='No'  id='choice_12_17_1'    \/>\n\t\t\t\t<label for='choice_12_17_1' id='label_12_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_18\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_18\" ><label class='gfield_label gform-field-label' >4- Difficulty breathing (e.g. shortness of breath or difficulty speaking)?<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_12_18'>\n\t\t\t<li class='gchoice gchoice_12_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Yes'  id='choice_12_18_0'    \/>\n\t\t\t\t<label for='choice_12_18_0' id='label_12_18_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_12_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='No'  id='choice_12_18_1'    \/>\n\t\t\t\t<label for='choice_12_18_1' id='label_12_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_20\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_20\" ><label class='gfield_label gform-field-label' >5- Sudden loss of smell (with or without loss of taste)?<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_12_20'>\n\t\t\t<li class='gchoice gchoice_12_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='Yes'  id='choice_12_20_0'    \/>\n\t\t\t\t<label for='choice_12_20_0' id='label_12_20_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_12_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='No'  id='choice_12_20_1'    \/>\n\t\t\t\t<label for='choice_12_20_1' id='label_12_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_21\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_21\" ><label class='gfield_label gform-field-label' >6- Muscle pain, headache, intense fatigue or severe loss of appetite?<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_12_21'>\n\t\t\t<li class='gchoice gchoice_12_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Yes'  id='choice_12_21_0'    \/>\n\t\t\t\t<label for='choice_12_21_0' id='label_12_21_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_12_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='No'  id='choice_12_21_1'    \/>\n\t\t\t\t<label for='choice_12_21_1' id='label_12_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_30\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_30\" ><label class='gfield_label gform-field-label' >7- Sore throat<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_12_30'>\n\t\t\t<li class='gchoice gchoice_12_30_0'>\n\t\t\t\t<input name='input_30' type='radio' value='Yes'  id='choice_12_30_0'    \/>\n\t\t\t\t<label for='choice_12_30_0' id='label_12_30_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_12_30_1'>\n\t\t\t\t<input name='input_30' type='radio' value='No'  id='choice_12_30_1'    \/>\n\t\t\t\t<label for='choice_12_30_1' id='label_12_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_31\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_31\" ><label class='gfield_label gform-field-label' >8- Diarrhea<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_12_31'>\n\t\t\t<li class='gchoice gchoice_12_31_0'>\n\t\t\t\t<input name='input_31' type='radio' value='Yes'  id='choice_12_31_0'    \/>\n\t\t\t\t<label for='choice_12_31_0' id='label_12_31_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_12_31_1'>\n\t\t\t\t<input name='input_31' type='radio' value='No'  id='choice_12_31_1'    \/>\n\t\t\t\t<label for='choice_12_31_1' id='label_12_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_12_32\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_32\" ><label class='gfield_label gform-field-label' >9- Have you been in close contact (at least 15 minutes within 2 meters) with a confirmed or probable case of 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_12_32'>\n\t\t\t<li class='gchoice gchoice_12_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Yes'  id='choice_12_32_0'    \/>\n\t\t\t\t<label for='choice_12_32_0' id='label_12_32_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice 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