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Home
About Us
Services
Patient Zone
Contact
Français
(514) 748-6586
COVID-19 SCREENING FORM FOR PATIENT / ACCOMPANYING VISITOR OF 6 MONTHS TO 5 YEAR-OLD
This form is completed:
*
When making the appointment (Pre-op)
At the time of the appointment (Op)
Name of screened individual:
*
Please indicate if the name above corresponds to the patient or the accompanying visitor:
*
Patient
Accompanying visitor
Name of patient:
*
Has the child tested Positive for COVID-19, or received a recommendation to take a screening test?
*
Yes
No
If you answered yes to question 1, is the child considered "recovered" by the regional public health department?
*
Yes
No
Has the child been instructed to self-isolate (example: return from a trip abroad for less than 14 days, contact with a confirmed case of COVID-19)?
*
Yes
No
Does the child have the following conditions:
Fever (≥ 38.5 ° C or 101.3 ° F)
*
Yes
No
Respiratory symptoms: cough (new or worsening), shortness of breath, difficulty breathing
*
Yes
No
Runny nose OR congestion OR sore throat AND moderate fever (between 38.1 ° C and 38.4 ° C or between 100.6 ° F and 101.1 ° F)
*
Oui
Non
Stomach ache OR vomiting OR diarrhea AND moderate fever (between 38.1 ° C and 38.4 ° C or between 100.6 ° F and 101.1 ° F)
*
Yes
No
Does the child have a known health condition that could explain the symptoms reported above? If yes, specify:
*
Yes
No
Not applicable
If yes, specify:
*
Has the child been in close contact (at least 15 minutes within 2 meters) with a confirmed or suspected case of COVID-19?
*
Yes
No
* This condition excludes healthcare workers who have provided care to a confirmed or suspected case of COVID-19 with the appropriate personal protective equipment.
Signature of the person who completed the form (parent or legal guardian):
*
Hidden
Date: