Health Check Screening Form Health Check Screening Form Paragraph Text This questionnaire must be completed by each individual prior to participation in each on-ice or off-ice activity. Are you currently experiencing any of these issues? Call 911 if you are. 1. Severe difficulty breathing (struggling for each breath, can only speak in single words). 2. Severe chest pain (constant tightness or crushing sensation). 3. Feeling confused or unsure where you are. 4. Losing consciousness. Paragraph Text If you are in any of the following risk groups, we ask that you speak with your physician prior to participating. 1. 70 years or older. 2. Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors). 3. Having a condition that compromises (weakens) your immune system (for example, diabetes, emphysema, asthma, heart condition). 4. Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment). Paragraph Text The answer to all questions must be "NO" in order to participate in any and all activity. 1. Are you currently experiencing any of these symptoms? Do you have a fever? (Feeling hot to the touch, a temperature of 37.8 C or higher) Checkboxes YES NO Single Line Text Checkboxes YES NO Single Line Text Cough that's new or worsening (continuous, more than usual) Checkboxes YES NO Single Line Text Barking cough, making a whistling noise when breathing (croup) Checkboxes YES NO Single Line Text Shortness of breath (out of breath, unable to breathe deeply) Checkboxes YES NO Single Line Text Checkboxes YES NO Single Line Text Checkboxes YES NO Single Line Text Runny nose, sneezing or nasal congestion (not related to seasonal allergies or other known causes or conditions) Checkboxes YES NO Single Line Text Checkboxes YES NO Single Line Text Checkboxes YES NO Single Line Text Checkboxes YES NO Single Line Text Checkboxes YES NO Single Line Text Checkboxes YES NO Single Line Text Checkboxes YES NO Single Line Text Checkboxes YES NO Single Line Text For young children and infants: sluggishness or lack of appetite Checkboxes YES NO Paragraph Text For the remaining questions, close physical contact means: Being less than 2 metres away in the same room, workspace, or area for over 15 minutes. Living in the same home. 2. In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19? Checkboxes YES NO Paragraph Text 3. In the last 14 days, have you been in close physical contact with a person who either: Is currently sick with a new cough, fever, or difficulty breathing; OR Returned from outside Canada in the last 2 weeks? Checkboxes YES NO Single Line Text Checkboxes YES NO Single Line Text If an individual answered "YES" to any of these questions, they are not permitted to participate in any on-ice or off-ice activities. Date Name Name: Submit