COVID-19 Screening

1. Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

Choose any/all that are new, worsening, and not related to other known causes or medical conditions.

Fever and/or chills

Yes No

Cough or Barking Cough (Croup)

Yes No

Shortness of Breath

Yes No

Decrease or Loss of Smell or Taste

Yes No

Sore Throat

Yes No

Difficulty Swallowing

Yes No

Pink Eye

Yes No

Runny or Stuffy/Congested Nose

Yes No

Headache that’s Unusual or Long Lasting

Yes No

Digestive Issues Like Nausea/Vomiting, Diarrhea, Stomach Pain

Yes No

Muscle Aches that are Unusual or Long Lasting

Yes No

Extreme Tiredness that is Unusual

Yes No

Falling Down Often

Yes No

2. Have you traveled outside of Canada in the past 14 days?(Please select NO, if you have travelled outside of Canada in the past 14 days and have followed provincial guidelines on re-entry into Ontario, or if you are an essential worker who crosses the Canada-US border regularly for work.)

Yes No

3. In the last 14 days has a public health unit identified you as a close contact of someone who currently has COVID-19?

Yes No

4. In the last 14 days have you had close contact with a confirmed or probable case of COVID-19 without wearing appropriate PPE?

Yes No

5. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Yes No

6. In the last 14 days, have you received a COVID Alert exposure notification on your cell? If you already went for a test and got a negative result, select “No”.

Yes No

Results of Screening Questions:
• If you have answered NO to all questions from 1 through 3, you have passed and can enter the Club.
• If you answered YES to any questions from 1 through 3, you have not passed and are not to enter the Club (including any outdoor or partially outdoor facility of the Club), and are to go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1-866-797-0000) to determine whether you need to get a COVID-19 test.

Acknowledgement
I confirm that I have answered the above questions honestly and truthfully, understand the contents herein, and that I am not to enter the Club if I answered YES to any of the questions above from 1 through 3.

Name

Email

example@example.com

Date

Signature

Clear