Health Screening Survey

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Please fill this Health Assessment before every class, camp or training at Deep Blue Athletics

Updated: September 1, 2020

If you have answer “YES” to any of the below questions do not participate. Proceed home and use the AHS Online Assessment Tool to determine if testing is recommended.

Email *

Guardian Full Name: *

Participant Full Name *

Do you have current symptoms of COVID-19 such as:

Fever *

Normal temperatures in children are*:Mouth: 35.5-37.5°C (95.9-99.5°F)Underarm: 36.5-37.5°C (97.7-99.5°)Ear (not recommended in infants): 35.8-38.0°C (96.4-100.4°F) *According to the Canadian Pediatric Society Children often feel warm to the touch when they have a fever. To confirm that your child has a fever, use a thermometer to measure your child’s body temperature. If your child’s temperature is higher than normal, he/she has a fever.

Yes

Required

New or changed chronic cough *

Yes

Required

Sore throat that is not related to a known or pre-existing condition *

Yes

Required

A runny nose that is not related to a known or pre-existing condition *

Yes

Required

Chills

Yes

Painful Swallowing

Yes

Feeling Unwell / Fatigued *

Yes

Required

Nasal congestion that is not related to a known or pre-existing condition *

Yes

Required

Shortness of breath that is not related to a known or pre-existing condition *

Yes

Required

Nausea / Vomiting /Diarrhea

Yes

Clear selection

Unexplained Loss of Appetite

Yes

Clear selection

Loss of sense of smell or taste

Yes

Clear selection

Muscle or Joint Pain

Yes

Headache

Yes

Clear selection

Conjunctivitis

Yes

Clear selection

Have you, or anyone in your household, returned from travel outside of Canada in the last 14 days? *

Yes

Required

Have you or your children attending the program had close unprotected contact (face-to-face contact within two-metres) with someone who is ill with cough and/or fever? *

Yes

Have you had unprotected close contact with an individual who has a confirmed or presumptive diagnosis of COVID-19 (For example, individuals exposed without appropriate PPE in use?) *

Yes

Required

CONSENT *

*I certify that the above information is correct to the best of my knowledge and that this information may be shared with AHS if requested due to a confirmed case of COVID-19.

Required

HAND WASHING *

* I AGREE to engage in appropriate hand washing both before and after my training. If outdoors, I will wash my hands prior to coming to training.

Required

Send me a copy of my responses.

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