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Santander Benefit Plan
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As part of the protocol, it is required to fill out an online questionnaire, you can continue your virtual consultation request by submitting the questionnaire.
Fill out the online questionnaire.
COVID-19 questionnaire
1. Have you had the following symptoms?
Fever
Yes
No
Cough
Yes
No
Headache
Yes
No
2. Has at least one of the following symptoms accompanied the prior?
Dyspnea (Difficulty breathing)
Yes
No
Arthralgia (joint myalgia)
Yes
No
Myalgia (muscle pain)
Yes
No
Odynophagia (sore throat)
Yes
No
Rhinorrhea (runny nose)
Yes
No
Conjunctivitis
Yes
No
Chest pain
Yes
No
Diarrhea
Yes
No
Abdominal pain
Yes
No
Other
3. You acknowledge yourself with:
Do you have Diabetes?
Yes
No
Hypertension
Yes
No
Cancer
Yes
No
Asthma
Yes
No
Obesity
Yes
No
Renal insufficiency
Yes
No
Do you smoke?
Yes
No
Autoimmune diseases
Yes
No
Other
4. Have you taken a trip?
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Where?
Date
5. Have you had contact with any patient who has had the above symptoms, suffers or is under investigation from COVID-19?
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