Covid Screening for MDMHA (Millbrook Minor Hockey)

Print Covid Screening for MDMHA
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)
  1. RadDatePicker
    Open the calendar popup.
  2. You will receive a confirmation of your submission to this address to show at the rink
  3. Example: ###-###-####
  1. The answer to all questions must be “No” in order to participate in any and all activity. If the answer is "yes" to any of the following symptoms please stay home.

    Are you currently experiencing any of these symptoms?

    1) Fever
    2) chills, 
    3) worsening cough, 
    4) shortness of breath, 
    5) sore throat difficult swallowing, 
    6) runny nose, 
    7) sneezing or nasal congestion (not related to allergies or other known conditions), 
    8) lost of smell or taste, 
    9) pink eye, 
    10) headache that is unusual or long lasting, 
    11) digestive issues (nausa/vomiting, diarrhea, stomach pain), 
    12) muscle aches, 
    13) extreme tiredness that is unusual, 
    falling down, 
    14) For young children and infants: sluggishness or lack of appetite

Assessment Continued
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
  1. 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.)
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Printed from on Sunday, September 19, 2021 at 3:39 AM