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The Field Hockey Zone Screening (Clinics)
This form is to be completed by anyone participating in The Field Hockey Zone Programs - specifically the Clinics
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* Indicates required question
Player Last Name
*
Your answer
Player First Name
*
Your answer
Symptoms
*
Have you had any of the following symptoms in the last 14 days
Yes
No
Headache
Sore Throat
Cough
Fever
Loss of taste or smell
Nauseau / vomiting
Diarrhea
Shortness of breath
Muscle aches
Congestion
Fatigue
Yes
No
Headache
Sore Throat
Cough
Fever
Loss of taste or smell
Nauseau / vomiting
Diarrhea
Shortness of breath
Muscle aches
Congestion
Fatigue
Contact
*
Have you been in close physical contact (less than 6 ft) for more than 15 minutes with anyone who was officially confirmed with a labratory covid test?
Choose
Yes
No
Tested
*
Have you been tested within the last 14 days
Yes
No
Positive Test
*
Have you tested positive at any point in time
Yes
No
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