Adult Sunday - COVID-19 Screening Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this form before arriving for training.

Email *

Please enter the name of the Player for whom you are completing this form. *

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. **Fever or chills **Cough or barking cough (croup) **Shortness of breath **Sore throat **Difficulty swallowing **Decrease or loss of smell or taste **Pink eye **Runny or stuffy/congested nose **Headache **Digestive issues like nausea/vomiting, diarrhea, stomach pain **Muscle aches **Extreme tiredness **Falling down often *

Yes

If you answered YES to the above question, which symptom(s) do you have?

Muscle aches; Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Runny or stuffy/congested nose; Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have

Sore throat; Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have

Extreme tiredness; Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

Difficulty swallowing; Painful swallowing not related to other known causes or conditions you already have

Pink eye; Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)

Fever and/or chills; Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough (croup); Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have

Shortness of breath; Not related to asthma or other known causes or conditions you already have

Headache; Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)

Decrease or loss of smell or taste; Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Falling down often; for older people

Digestive issues like nausea/vomiting, diarrhea, stomach pain; Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have

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

Yes

In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19? *

Yes

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? *

Yes

In the last 14 days, have you or anyone you live with travelled outside of Canada? *

Yes

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *

Yes

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Huntsville Soccer Club. Report Abuse

Forms