COVID 19 Self- Assessment Form
Mandated by City of Markham - This form must be filled out every time you play at the tennis club per court booking per day.
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Enter  Court booking date & start time *
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Time
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Full Name *
Phone Number *
Email Address *
Please review the following statements:
1. Have you been tested for COVID-19 AND are awaiting results?
2. Have you been directed by Public Health, Telehealth or a physician to self-isolate for a period of time including today?
3. Do you have any of the following (otherwise unexplained) new or worsening, signs or symptoms:
- Fever or chills;
- Cough (new or worsening), barking cough; a squeaky or whistling noise when breathing (croup); severe difficulty breathing or - shortness of breath;
- Sore throat, hoarse voice, difficulty swallowing;
- Stuffy, congested or runny nose;
- Severe chest pains;
- Loss of consciousness;
- Feeling confused or unsure of where you are;
- Not feeling well;
- Falling down often;
- Extreme tiredness that is unusual, lack of energy, sluggishness;
- Muscle aches that are unusual or long lasting;
- Headache (unusual or long lasting);
- Conjunctivitis (pink eye);
- Decrease in or loss of smell or taste; lack of appetite;
- Digestive issues (nausea/vomiting, diarrhea, stomach pain);
 4. In the last 14 days, have you had close contact* with someone who:
 
a. Has or is suspected of having COVID-19 (including exhibiting any of the listed symptoms and/or awaiting test results)?

b. Has returned from outside of Canada in the last 14 days?
Did you answer Yes to ANY of the above questions *
Statement *
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