2021 Hockey Covid Screening Form – electriccityspecialneedshockey

Email *

Name Of Individual *

Contact Number *

How old are you? *

17 years old or younger
18 years old or older

We collect this anonymous information to ask age-specific questions.

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. *

Fever and/or chillsTemperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Cough or barking cough (croup)Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)
Shortness of breathOut of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)
Decrease or loss of taste or smellNot related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
Sore throat or difficulty swallowingPainful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions you already have)
Runny or stuffy/congested noseNot related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have
HeadacheUnusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)
Digestive issues like nausea/vomiting, diarrhea, stomach painNot related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have
Extreme tiredness or muscle achesUnusual, fatigue, lack of energy, poor feeding in infants (not related to getting a COVID-19 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction, sudden injury, or other known causes or conditions you already have)
None of the above

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? If you are fully vaccinated (it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series), select “No.” If the person got a COVID-19 vaccine in the last 48 hours and is experiencing a mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” *

Yes
No

In the last 14 days, have you travelled outside of Canada? If exempt from federal quarantine requirements (for example, you are fully vaccinated and have met the specific conditions, or an essential worker who crosses the Canada-US border regularly for work), select “No.” *

Yes
No

In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19? If you are fully vaccinated (it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series) and have not been told to self-isolate by public health, select “No.” *

Yes
No

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing. *

Yes
No

In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select "No." *

Yes
No

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you are fully vaccinated (it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series), select “No.” If you already went for a test and got a negative result, select “No.”

Yes
No