CK Crush - COVID Screening Questionnaire

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This questionnaire must be completed by each individual prior to participation in any CKGHA team activities. The answer to all questions must be 'No' in order to participate.

Name (First Last) *

YYYY

Do you have chills? *

Yes

Do you have a Fever? *

Yes

Are you experiencing any of the following symptoms:

Cough that's new or worsening (continuous, more than usual)

Barking Cough, making a whistling noise when breathing

Shortness of breath (out of breath, unable to breath deeply_

Runny nose, sneezing (not related to seasonal allergies or other known causes or conditions)

Stuffy or congested nose (not related to seasonal allergies or other known causes or conditions)

Sore throat

Difficulty swallowing

Loss of sense of taste or smell

Pink Eye

Headache that is unusual or long lasting

Digestive issues like nausea / vomiting, diarrhea, stomach pain (not related to other known causes or conditions)

Muscle aches that are unusual or long lasting

Extreme tiredness that is unusual (fatigue, lack of energy)

Falling down often

For young children and infants: Sluggishness or lack of appetite

None of the above

In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19? Close physical contact means: being less than 2 metres away in the same room, workspace, or area; living in the same home. * *

Yes

In the last 14 days, have you been in close physical contact with a person who is currently sick with a new cough, fever, or difficulty breathing? * *

Yes

In the last 14 days, have you been in close physical contact with someone who returned from outside of Canada in the last 2 weeks, and is not an essential worker with exemption from mandatory quarantine? *

Yes

Have you traveled outside of Canada in the last 14 days? (This does not include essential workers who cross the Canada-US border regularly) * *

Yes

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