Health Screening Questionnaire
APPENDIX A
HEALTH SCREENING QUESTIONNAIRE
This questionnaire must be completed verbally by each individual prior to participation in each skating class.
If an individual answers YES to any of the questions, they must not be allowed to participate in the skating program. Children and youth may need a parent to assist them to complete this screening tool.
| 1. | Do you/your child have any new-onset (or worsening) of any of the following symptoms? | CIRCLE ONE | |
| Fever | YES | NO | |
| Cough | YES | NO | |
| Shortness of breath / Difficulty breathing | YES | NO | |
| Sore throat | YES | NO | |
| Chills | YES | NO | |
| Painful swallowing | YES | NO | |
| Runny nose / Nasal congestion | YES | NO | |
| Feeling unwell / Fatigued | YES | NO | |
| Nausea / Vomiting / Diarrhea | YES | NO | |
| Unexplained loss of appetite | YES | NO | |
| Loss of sense of taste or smell | YES | NO | |
| Muscle / joint aches (unrelated to training) | YES | NO | |
| Headache | YES | NO | |
| Conjunctivitis (commonly known as pink eye) | YES | NO | |
| 2. | Has the person attending the activity / facility traveled outside of Canada in the last 14 days? | YES | NO |
| 3. | Have you/your child had close, unprotected* contact (face to face contact within 2 metre/6 feet) with someone who has traveled outside of Canada in the last 14 days and who is ill**? | YES | NO |
| 4. | Have you/your child attending the program or activity had close, unprotected* contact (face to face contact within 2 metre/6 feet) in the last 14 days and who is ill**? | YES | NO |
| 5. | Have you/your child or anyone in your household been in close, unprotected* contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19? | YES | NO |
* “unprotected” means close contact without appropriate personal protective equipment.
** “ill” means someone with COVID-19 symptoms on the list above.
If you have answered YES to any of the above questions do not participate. Proceed home and use the AHS Online Health Assessment Tool to determine if testing is recommended.
