Risques infectieux

Prenez soin de votre santé – et de celle des autres !

Health Survey

Health Survey / Questionnaire de santé / استبيان الصحة

Choose your language / Choisissez votre langue / اختر لغتك

Who is taking this survey?

Myself
Someone is doing it for me

What symptoms do you have? (You can choose more than one)

Unresolved Cough
Night sweats
Fever
Headache / Migraines
Bloody cough
Back pain
Sudden weight loss
Thoracic pain
Extreme Fatigue
Breathing difficulties
Other symptoms
None

When did your symptoms first manifest?

A couple of days ago
A couple of weeks ago
A year ago
More than a year ago
I don't recall
I don't have any of the symptoms stated

Do you have any of the following conditions?

HIV
Other STI (Syphilis, Chlamydia, Gonorrhea, etc.)
Diabetes
Cholesterol
Heart problems
Respiratory problems
Underweight / overweight
None of the above

Emergency Contact / Contact d'urgence / الاتصال في حالات الطوارئ

If high risk, please contact CLAT immediately at: / En cas de risque élevé, veuillez contacter le CLAT immédiatement au : / في حالة الخطر المرتفع، يرجى الاتصال بـ CLAT على الفور:

04 72 73 12 76 or 04 72 19 84 00

Mentions légales
Politique de confidentialité

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