TBWHA Health Screening Form

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This Health Screening questionnaire must be completed by each individual prior to participating in each on-ice or off-ice activity.

Are you currently experiencing any of the following issues? Call 911 if you are.
1. Severe difficulty breathing (struggling for each breath, can only speak in single words)
2. Severe chest pain (constant tightness or crushing sensation)
3. Feeling Confused or unsure of where you are
4. Losing consciousness

If you are in any of the following risk groups, we ask that you speak with your physician prior to participating.
1. 70 years or older
2. Getting treatment that compromises (weakens) your immune system (ex. chemotherapy, medications for transplants, corticosteroids, TNF inhibitors)
3. Having a condition that compromises (weakens) your immune system (ex. diabetes, emphysema, asthma, heart condition)
4. Regularly going to a hospital or health care setting for treatment (ex. dialysis, surgery, cancer treatment)

PLEASE NOTE THIS FORM MUST BE COMPLETED WITHIN 6 HOURS OF THE START OF YOUR ACTIVITY.

The answer to all questions must be 'NO' in order to participate in each on-ice activity. Answering this form truthfully is the responsibility of all players/parents.

Are you experiencing any of these symptoms? Fever over 37.8C, chills, cough (that's new or worsening), barking cough (making a whistling noise when breathing), shortness of breath, sore throat, difficulty swallowing, runny nose, sneezing or nasal congestion (not related to seasonal allergies), lost sense of taste or smell, pink eye (conjunctivitis), headache that's unusual or long lasting, digestive issues (nausea/vomiting, diarrhea, stomach pain), muscle aches, extreme tiredness that is unusual (fatigue, lack of energy) falling down often, sluggishness or lack or appetite? *

Yes

Required

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