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
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    Open the calendar popup.
  2. Players First Name / Players Last Name
  3. If Under 18 Years of Age
  4. 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?
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
Human Validation
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Printed from suncountypanthers.com on Saturday, October 31, 2020 at 12:44 PM