2021-22 COVID Health Screen (Caledonia Old Timers Hockey)

Print 2021-22 COVID Health Screen

Player Information

First Name^*
Last Name^*
Cell Phone Number^*

Example: ###-###-####
Email Address^*

Example: [email protected] Your submission will be sent to this address.

Hockey & Game Information

Game Date^*

Health Question 1: Are you currently experiencing any of these symptoms?

Please answer all questions. The answer to all questions must be “No” in order to participate in any and all activity.

Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher)^*
YesNo
Do you have the Chills?^*
YesNo
Do you have a cough that’s new or worsening (continuous, more than usual) ^*
YesNo
Do you have a Barking cough, making a whistling noise when breathing (croup) ^*
YesNo
Do you have Shortness of breath (out of breath, unable to breathe deeply)^*
YesNo
Do you have a sore throat or difficulty swallowing^*
YesNo
Do you have a runny nose, sneezing or nasal congestion (not related to seasonal allergies or other known causes or conditions)^*
YesNo
Do you have a lost sense of taste or smell^*
YesNo
Do you have pink eye (conjunctivitis) ^*
YesNo
Do you have a headache that’s unusual or long lasting ^*
YesNo
Do you have digestive issues (nausea/vomiting, diarrhea, stomach pain) ^*
YesNo
Do you have muscle aches ^*
YesNo
Do you have extreme tiredness that is unusual (fatigue, lack of energy) ^*
YesNo
Are you falling down often ^*
YesNo

Health Background Questions 2 thru 4

Please answer all questions. The answer to all questions must be “No” in order to participate in any and all activity

2. In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?^*
YesNo
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 of Canada in the last 2 weeks? ^*
YesNo
(This does not include essential workers who cross the Canada-US border regularly.)
4. Have you travelled outside of Canada in the last 14 days? ^*
YesNo
(This does not include essential workers who cross the Canada-US border regularly.)

Human Validation

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Sun Sep 19, 2021

Printed from caledoniaoldtimershockey.com on Sunday, September 19, 2021 at 3:59 AM