LMHA U7 COVID-19 Assessment
This form must be filled out the day of the player participating in any in-person LMHA activity.  If you answer “YES” to any of the questions, please do not attend the activity, and contact AHS/811 to plan your next steps.  
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Email *
Player Name (FIRST & LAST) *
Date of activity *
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Time of Activity *
Time
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Is your athlete attending this session?  If he or she is NOT attending due to health reasons, please contact covidinfo@lmha.ab.ca.   *
Do you have any severe difficulties breathing? Severe chest pain? Having a hard time waking up? Feeling confused? Lost consciousness? *
Do you have any shortness of breath at rest? Inability to lie down because of difficulty breathing? Chronic health conditions that you are having difficulty managing because of your current respiratory illness? *
In the past 14 days have you experienced any of the following? Fever? New onset of coughing or worsening of chronic cough? New or worsening difficulty breathing? *
Do you have any of the following: Chills, painful swallowing, stuffy nose, headache, muscle or joint ache, feeling unwell, fatigue or severe exhaustion, nausea, vommiting, diarrhea, unexplained loss of appetite, loss of sense of smell/taste or pink eye (conjunctivitis) *
In the past 14 days, did you return from travel outside of Canada? *
In the past 14 days, have you been a close contact of someone who has had a positive test result for Covid-19? *
In the past 10 days have you tested positive for Covid-19 or are you awaiting test results from a Covid-19 test? *
IF YOU HAVE ANSWERED “YES”  TO ANY OF THE ABOVE QUESTIONS...
IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS - PLEASE DO NOT ATTEND ANY LMHA ACTIVITIES. PLEASE CALL 811 AND SPEAK TO AN AHS NURSE ABOUT YOUR SYMPTOMS
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