Health survey pre-appointment

Last name

First name

Age

Phone number

E-mail

Do you suffer from heart, lung, kidney or liver problems?

Yes

No

If yes, specify

Do you have unbalanced diabetes?

yes

No

Do you have a condition or treatment that lowers your immunity?

Yes

No

If yes, specify

Your height

Your weight

Are you pregnant in the 3rd trimester of pregnancy?

yes

No

A person with the above signs?

Yes

No

A person diagnosed with COVID-19?

Yes

No

ave you tested positive for COVID-19?

Yes

No

Number of days since the end of having a cold

Number of days since the end of a respiratory difficulty

Number of days since onset of symptoms

DR PIERRE PORTA - DR LÉA LEVAN - DR CLÉMENTINE CANTE