U13 Team #3 - Health Screening Questionaire (Millbrook Minor Hockey)

Print U13 Team #3 - Health Screening Questionaire

Your Information

Please provide name for who the document is for (i.e. if player documents provide players name and provide parent/guardian info in the extra box provided)

Date^*

Open the calendar popup.

Players First Name
Players Last Name
Parent/Guardian For Name Above (First & Last) (if applicable)
If Bench Staff - Full Name
Email Address^*

You will receive a confirmation of your submission to this address to show at the rink
Phone Number^*

Example: ###-###-####

Are you currently experiencing?

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 37.8C or higher) ^*
NoYes
Chills?^*
NoYes
Cough that's new or worsening? (continuous, more than usual)^*
NoYes
Barking cough, making a whistling noise when breathing (croup)?^*
NoYes
Shortness of Breath? (out of breath, unable to breathe deeply)^*
NoYes
Sore Throat?^*
NoYes
Difficulty Swallowing?^*
NoYes
Runny nose, sneezing or nasal congestion (not related to seasonal allergies or other known causes or conditions)^*
NoYes
Lost sense of taste or smell?^*
NoYes
Pink eye? (conjunctivitis)^*
NoYes
Headache that is unusual or long lasting?^*
NoYes
Digestive issues? (nausea/ vomiting, diarrhea, stomach pain)^*
NoYes
Muscle Aches?^*
NoYes
Extreme tiredness that is unusual? (fatigue, lack of energy)^*
NoYes
Falling down often?^*
NoYes
For young children and infants: Sluggish or lack of appetite?^*
NoYes

Close Physical Contact means:

Being less than 2 meters away in the same room, workspace, or area for over 15 minutes Living in the same home

In the last 14 days, have you been in close physical contact with someone who tested positive for Covid-19?^*
NoYes
In the last 14 days, have you been in close physical contact with a person who is either currently sick with a cough, fever or difficulty breathing?^*
NoYes
In the last 14 days, have you been in close physical contact with a person who has returned from outside Canada in the last 2 weeks?^*
NoYes
Have you traveled outside of Canada in the last 14 days?^*
NoYes

This questionnaire must be completed by each individual prior to participation in EACH on ice or off ice activity.

Please call 911 if you are experiencing:
1. Severe difficulty breathing (struggling for each breath, can only speak in single words).
2. Severe chest pain (constant or tightness or crushing sensation).
3. Feeling confused or unsure where you are.
4. Losing consciousness.

If you are in any of the following wish groups, we ask that you speak with your physician prior to participating.
1. 70 years old 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 conditions.)
4. Regularly going to a hospital or health care setting for a treatment. (For example, dialysis, surgery, cancer treatment.)

I agree to the terms and conditions stated above^*