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    {"id":20,"date":"2020-05-28T12:27:03","date_gmt":"2020-05-28T16:27:03","guid":{"rendered":"https:\/\/orthoperfection.com\/protocole\/?page_id=20"},"modified":"2020-05-28T13:33:27","modified_gmt":"2020-05-28T17:33:27","slug":"questionnaire-francais","status":"publish","type":"page","link":"https:\/\/orthoperfection.com\/protocole\/","title":{"rendered":"Questionnaire francais"},"content":{"rendered":"<p><span style=\"font-size: 24px;\"><strong>Questionnaire de d\u00e9pistage du patient et accompagnateur \u2013 COVID-19<\/strong><\/span><br \/>\n<strong>\u00a0<\/strong>En cette p\u00e9riode particuli\u00e8re de la COVID-19, chaque patient (et accompagnateur s\u2019il y a n\u00e9cessit\u00e9) doit avoir compl\u00e9t\u00e9 ce formulaire pour assurer votre sant\u00e9 et s\u00e9curit\u00e9, ainsi que celles des autres patients et membres du personnel.<br \/>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/protocole\/wp-json\/wp\/v2\/pages\/20' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_33\" class=\"gfield gfield--type-text gf_readonly field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'>Date avant le rendez-vous<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_1_33' type='text' value='16 avril 2026 18h49' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Nom de la personne d\u00e9pist\u00e9e<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_1_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Veuillez indiquer si le nom ci-dessus correspond au formulaire de d\u00e9pistage du patient ou de l\u2019accompagnateur:<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_1_13'>\n\t\t\t<li class='gchoice gchoice_1_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Patient'  id='choice_1_13_0'    \/>\n\t\t\t\t<label for='choice_1_13_0' id='label_1_13_0' class='gform-field-label gform-field-label--type-inline'>Patient<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Accompagnateur'  id='choice_1_13_1'    \/>\n\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>Accompagnateur<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>Nom du patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_15\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1- Avez-vous eu un test de d\u00e9pistage positif \u00e0 la COVID-19 depuis moins de 21 jours ou \u00eates-vous en attente de r\u00e9sultat d\u2019un test de d\u00e9pistage?<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_1_15'>\n\t\t\t<li class='gchoice gchoice_1_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Oui'  id='choice_1_15_0'    \/>\n\t\t\t\t<label for='choice_1_15_0' id='label_1_15_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='Non'  id='choice_1_15_1'    \/>\n\t\t\t\t<label for='choice_1_15_1' id='label_1_15_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_25\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#b40060;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">Pr\u00e9sentez-vous les conditions suivantes :<\/div><\/li><li id=\"field_1_16\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2- Fi\u00e8vre (plus de 38\u00b0C ou 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_1_16'>\n\t\t\t<li class='gchoice gchoice_1_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Oui'  id='choice_1_16_0'    \/>\n\t\t\t\t<label for='choice_1_16_0' id='label_1_16_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='Non'  id='choice_1_16_1'    \/>\n\t\t\t\t<label for='choice_1_16_1' id='label_1_16_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_17\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3- Toux r\u00e9cente ou chronique qui s\u2019est aggrav\u00e9e<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_1_17'>\n\t\t\t<li class='gchoice gchoice_1_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Oui'  id='choice_1_17_0'    \/>\n\t\t\t\t<label for='choice_1_17_0' id='label_1_17_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='Non'  id='choice_1_17_1'    \/>\n\t\t\t\t<label for='choice_1_17_1' id='label_1_17_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_18\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4- Difficult\u00e9 respiratoire (par exemple : essoufflement ou difficult\u00e9 \u00e0 parler)<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_1_18'>\n\t\t\t<li class='gchoice gchoice_1_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Oui'  id='choice_1_18_0'    \/>\n\t\t\t\t<label for='choice_1_18_0' id='label_1_18_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='Non'  id='choice_1_18_1'    \/>\n\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_20\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5- Perte subite de l\u2019odorat (avec ou sans perte du go\u00fbt)<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_1_20'>\n\t\t\t<li class='gchoice gchoice_1_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='Oui'  id='choice_1_20_0'    \/>\n\t\t\t\t<label for='choice_1_20_0' id='label_1_20_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='Non'  id='choice_1_20_1'    \/>\n\t\t\t\t<label for='choice_1_20_1' id='label_1_20_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_21\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >6- Douleurs musculaires, mal de t\u00eate, fatigue intense ou importante perte d\u2019app\u00e9tit<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_1_21'>\n\t\t\t<li class='gchoice gchoice_1_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Oui'  id='choice_1_21_0'    \/>\n\t\t\t\t<label for='choice_1_21_0' id='label_1_21_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='Non'  id='choice_1_21_1'    \/>\n\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_30\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >7- Mal de gorge<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_1_30'>\n\t\t\t<li class='gchoice gchoice_1_30_0'>\n\t\t\t\t<input name='input_30' type='radio' value='Oui'  id='choice_1_30_0'    \/>\n\t\t\t\t<label for='choice_1_30_0' id='label_1_30_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_30_1'>\n\t\t\t\t<input name='input_30' type='radio' value='Non'  id='choice_1_30_1'    \/>\n\t\t\t\t<label for='choice_1_30_1' id='label_1_30_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_31\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >8- Diarrh\u00e9e<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_1_31'>\n\t\t\t<li class='gchoice gchoice_1_31_0'>\n\t\t\t\t<input name='input_31' type='radio' value='Oui'  id='choice_1_31_0'    \/>\n\t\t\t\t<label for='choice_1_31_0' id='label_1_31_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_31_1'>\n\t\t\t\t<input name='input_31' type='radio' value='Non'  id='choice_1_31_1'    \/>\n\t\t\t\t<label for='choice_1_31_1' id='label_1_31_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_32\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >9- Avez-vous \u00e9t\u00e9 en contact \u00e9troit (au moins 15 minutes \u00e0 moins de 2 m\u00e8tres) avec un cas confirm\u00e9 ou probable de la 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_1_32'>\n\t\t\t<li class='gchoice gchoice_1_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Oui'  id='choice_1_32_0'    \/>\n\t\t\t\t<label for='choice_1_32_0' id='label_1_32_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='Non'  id='choice_1_32_1'    \/>\n\t\t\t\t<label for='choice_1_32_1' id='label_1_32_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_2'>Signature de la personne qui a rempli le formulaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_2' id='input_1_2_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_2_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_1_2' width='600' height='180' style='border-style: solid; border-width: 1px; border-color: #9e005c; background-color:#fff1f8; cursor: url(https:\/\/orthoperfection.com\/protocole\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_1_2_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_1_2_resetbutton' 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