Health (Covid) Screening Questionnaire

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To be completed prior to ALL on-ice or off-ice activity.

Please speak with your physician prior to participating if any of these risk groups apply to you.

1. You receive treatment that compromises (weakens) your immune system ie. chemotherapy, medication for transplants, corticosteroids, TNF inhibitors.
2. You have a condition that compromises (weakens) your immune system ie. diabetes, emphysema, asthma, heart condition.
3. You regularly go to a hospital or health care setting for a treatment ie. dialysis, surgery, cancer treatment.

Please call 911 if you are experiencing any of the following symptoms.

1. Severe difficulty breathing.
2. Severe chest pain.
3. Feeling confused or unsure of where you are.
4. Losing consciousness.

Please select your name from the list. *

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