OHF Health Screening Questionnaire (Sun County Panthers)

Print OHF Health Screening Questionnaire

This questionnaire must be completed by each individual prior to participation in each on-ice or off-ice activity. This questionnaire may be completed verbally. Are you currently experiencing any of these issues? Call 911 if you are. • Severe difficulty breathing (struggling for each breath, can only speak in single words) • Severe chest pain (constant tightness or crushing sensation) • Feeling confused or unsure of where you are • Losing consciousness If you are in any of the following at risk groups, we ask that you speak with your physician prior to participating. • Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors) • Having a condition that compromises (weakens) your immune system (for example, lupus, rheumatoid arthritis, immunodeficiency disorder) • Having a chronic (long-lasting) health condition (for example, diabetes, emphysema, asthma, heart condition, COPD) • Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment) The answer to all questions must be “No” in order to participate in any and all activity.

Player / Coach Information

Date^*

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Players Name^*

Players First Name / Players Last Name
Parent / Guardian Name^*

If Under 18 Years of Age
Contact Phone Number^*

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

OHF Health Screening Questionnaire

The answer to all questions must be “No” in order to participate in any and all activity. 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)^*
YesNo
Chills^*
YesNo
Cough that’s new or worsening (continuous, more than usual)^*
YesNo
Barking cough, making a whistling noise when breathing (croup)^*
YesNo
Shortness of breath (out of breath, unable to breathe deeply)^*
YesNo
Sore Throat^*
YesNo
Difficulty Swallowing^*
YesNo
Runny nose, sneezing or nasal congestion (not related to seasonal allergies or other known causes or conditions)^*
YesNo
Lost sense of taste or smell^*
YesNo
Pink eye (conjunctivitis)^*
YesNo
Headache that’s unusual or long lasting^*
YesNo
Digestive issues (nausea/vomiting, diarrhea, stomach pain)^*
YesNo
Muscle aches^*
YesNo
Extreme tiredness that is unusual (fatigue, lack of energy)^*
YesNo
Falling down often^*
YesNo
For young children and infants: sluggishness or lack of appetite^*
YesNo

OHF Health Screening Questionnaire

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

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

Human Validation

Check The Box ^*

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Sat Oct 31, 2020

Printed from suncountypanthers.com on Saturday, October 31, 2020 at 12:44 PM