Coronavirus COVID-19

NAME OF PERSON SCREENED*

Please indicate if the above name matches the patient or accompanying person screening form:

Patient

accompanying

If 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*

Yes

CLINIC*

Yes

2-Fever (over 38 ° C or 100.4 ° F)

PRE-APPT*

Yes

CLINIC*

Yes

3-Recent or chronic cough that has gotten worse

PRE-APPT*

Yes

CLINIC*

Yes

4-Difficulty breathing (e.g. shortness of breath or difficulty speaking)

PRE-APPT*

Yes

CLINIC*

Yes

5-Sudden loss of smell (with or without loss of taste)

PRE-APPT*

Yes

CLINIC*

Yes

6-Muscle pain, headache, intense fatigue or severe loss of appetite

PRE-APPT*

Yes

CLINIC*

Yes

7-Sore throat

PRE-APPT*

Yes

CLINIC*

Yes

8-Diarrhea

PRE-APPT*

Yes

CLINIC*

Yes

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*

Yes

CLINIC*

Yes

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 signed

PRE-APPT Signature :*

Clinic Signature :*

THIS SECTION IS RESERVED FOR STAFF OF TORO CLINICS

If 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-APPT

Asymptomatic

Suspected / Confirmed

If the patient is considered COVID-19 suspected / confirmed, consult the dentist before scheduling an appointment.

Are you human ?*

This field should be left blank

SHEET 2A: PATIENT / ACCOMPANIMENT SCREENING FORM

(confidential shipment)

Please indicate if the above name matches the patient or accompanying person screening form:

1-Have you had a positive COVID-19 test in less than 21 days or are you waiting for a test result?

2-Fever (over 38 ° C or 100.4 ° F)

3-Recent or chronic cough that has gotten worse

4-Difficulty breathing (e.g. shortness of breath or difficulty speaking)

5-Sudden loss of smell (with or without loss of taste)

6-Muscle pain, headache, intense fatigue or severe loss of appetite

7-Sore throat

8-Diarrhea

9-Have you been in close contact (at least 15 minutes within 2 meters) with a confirmed or probable case of COVID-19?

Signature of the person who completed the form (patient or office staff):

THIS SECTION IS RESERVED FOR STAFF OF TORO CLINICS