Coronavirus COVID-19 SHEET 2A: PATIENT / ACCOMPANIMENT SCREENING FORM (confidential shipment) NAME OF PERSON SCREENED*Please indicate if the above name matches the patient or accompanying person screening form:PatientaccompanyingIf accompanying person, name of patient:PRE-APPT (choose date)CLINIC (choose date)DO YOU HAVE THE FOLLOWING CONDITIONS:1-Have you had a positive COVID-19 test in less than 21 days or are you waiting for a test result?PRE-APPT*YesNoCLINIC*YesNo2-Fever (over 38 ° C or 100.4 ° F)PRE-APPT*YesNoCLINIC*YesNo3-Recent or chronic cough that has gotten worsePRE-APPT*YesNoCLINIC*YesNo4-Difficulty breathing (e.g. shortness of breath or difficulty speaking)PRE-APPT*YesNoCLINIC*YesNo5-Sudden loss of smell (with or without loss of taste)PRE-APPT*YesNoCLINIC*YesNo6-Muscle pain, headache, intense fatigue or severe loss of appetitePRE-APPT*YesNoCLINIC*YesNo7-Sore throatPRE-APPT*YesNoCLINIC*YesNo8-DiarrheaPRE-APPT*YesNoCLINIC*YesNo 9-Have you been in close contact (at least 15 minutes within 2 meters) with a confirmed or probable case of COVID-19?PRE-APPT*YesNoCLINIC*YesNo Signature of the person who completed the form (patient or office staff):By completing this mandatory field with your full name, you validate this document as being signedPRE-APPT Signature :*Clinic Signature :*THIS SECTION IS RESERVED FOR STAFF OF TORO CLINICSIf the patient responded: YES to question 1: SUSPECTED / CONFIRMED STATUS. YES to at least one of questions 2 to 5 AND YES to question 9: STATUS SUSPECTED / CONFIRMED. YES to at least two of questions 6 to 8 AND YES to question 9: SUSPECTED / CONFIRMED STATUS. Any other answer: ASYMPTOMATIC STATUS.PRE-APPTAsymptomaticSuspected / Confirmed If the patient is considered COVID-19 suspected / confirmed, consult the dentist before scheduling an appointment. Are you human ?*SendThis field should be left blank