Your self-assessment is uniquely identified via a code indicated in the report. This code is KEY as it allows you to retrieve the results of the questionnaire that you will have printed before coming for your scheduled visit.

If you have not been able to print this document, or if you have lost it, only this identifier will allow us to find the results of your self-assessment, which is essential for your entry into the institution.

So please keep it safe. It is at the top of the report that you receive by email before you print it, you can also take a screenshot from your computer or smartphone. You can copy it and keep it with your other documents (health card, health insurance certificate, ...).

If you forget or lose this identifier, it is not possible to find the result of your self-assessment and will have to be redone when you come.

Before you came to our hospital:

• In the event of hospitalization, you will be asked to fill out this questionnaire upon your arrival in order to organize your stay in complete safety and to offer you appropriate care in this epidemic context.
• In the event of a consultation, your doctor may ask you to do so before coming to the premise or may suggest that you fill it out before a teleconsultation.
  The important thing is that this self-assessment should be carried out in a fairly short time before you come, in order to have the most up-to-date information possible, particularly with regard to any symptoms that may have appeared since your last consultation.

Please ensure you complete this self a fairly short time before you come (D-2), in order to have the most up-to-date information possible, particularly with regard to any symptoms that may have appeared since your last consultation.

Ideally, on the evening two days before your scheduled visit you should take this assessment. That will give you time to discuss with your referring doctor or our teams in case of new or unusual elements. In case of planned hospitalization, you will be contacted the day before (D-1) and you will be able to indicate at this time the result of the evaluation, which will allow us to adapt the treatment offered to you if necessary. During this call, you will receive useful information for your arrival and answers to the questions you have.

At any time

You can use this self-assessment questionnaire at any time if you have any doubts, or if unusual symptoms appear. Depending on the orientations that will be proposed to you at the end of the evaluation, you may contact your referring doctor at the clinic and/or your attending physician to inform them of these new elements.

First of all, it is important that anyone who needs to seek treatment can do so safely and without delay. The period of confinement has imposed constraints on the distancing necessary to block the spread of the virus, but has also postponed necessary medical treatment that must now be provided without further delay.

Our country is entering a delicate phase of de-confinement, which imposes on all of us an increased vigilance and some necessary constraints without neglecting your state of health. This self-assessment questionnaire is part of this vigilance and will allow us to evaluate the risk that you have encountered the virus with possible consequences for your health and that of your loved ones.

Whatever the result, it will enable us to offer you a treatment adapted to the risk of Covid, by ensuring the continuity of care necessary and justified by your state of health. In certain situations, it will be advised to you before your arrival, to contact your doctor, the one who follows you in the establishment or your general practitioner, in order to propose a new consultation in the surgery or in tele-consultation to adapt the care to your situation of the moment.

• Either there are no unusual elements and your evaluation does not find anything that could suggest an encounter with the virus. You go to our site with a copy of your questionnaire. It will be taken into account and your course will take place as explained to you by your referring doctors.
• Either there are unusual elements and your evaluation finds elements that could evoke an encounter with the virus. You will then be advised to contact your referring doctor at the clinic to adjust your care in the light of these elements. These new elements may not be related to the epidemic, because of another disease that could give the same signs for example, but the context recommends to all of us the utmost caution which justifies this adaptation of your management in case of suspicious signs.
• Either there are worrying elements and in this case you will be advised to contact the centre 15, failing that, your general practitioner and to have your referring doctor inform you of the impossibility for you to come to our site. These elements may be related to the Covid but also to another illness or complication of your state of health which would give the same signs. For this reason you should not come and contact an emergency structure as soon as possible.

The information entered in this questionnaire is anonymous. It is personal and only you are able to entrust it to a health professional authorised to access it in accordance with the regulations concerning data protection, particularly health data.

Vivalto Santé is required to collect information on your state of health in the context of the fight against and prevention of the spread of the Covid-19 epidemic. This information is kept for the duration of the Covid crisis or failing that for a period of 1 year in anonymous form and will not be communicated to a third party.

Your data are only recorded if you fill in the form to the end, your answers are sent to a server and remain anonymous: your IP address is not collected. Your e-mail address for sending the evaluation result is dissociated from the evaluation and is not stored.

Exercising your rights

For any information or to exercise your rights to information technology and freedom regarding the processing of personal data managed by an establishment of the Vivalto santé group, you can contact the management of the establishment or the Data Protection Officer (DPO) by email: dpd@vivalto-sante.com.

In the event of difficulties, you can also file a complaint with the Commission Nationale de l'Informatique et des Libertés (CNIL).