Covid Health Questionaire

 

Appendix E- Health Screening Questionnaire Template

 

This questionnaire must be completed by each individual daily prior to participation in each club activity.

This questionnaire may be completed verbally.

 

The answer to all questions must be “No” in order to participate in each club activity.

 

Participant Name:__________________________________   Date:_______________________

 

1.     Do you have a fever? (a temperature of 37.8C or higher)

Yes ™                                       No ™   

 

2. Do you have any of the following symptoms?

• Cough                                                          

Yes ™                                       No ™   

• Shortness of breath                                                

Yes ™                                       No ™   

• Runny nose, sneezing or nasal congestion(not related to other known causes such as

seasonal allergies etc.)          

Yes ™                                       No ™   

• Sore throat

Yes ™                                       No ™   

• Difficulty swallowing

Yes ™                                       No ™   

• Lost sense of taste or smell

Yes ™                                       No ™   

3. Have you or someone in your household travelled outside of Canada or had close contact with anyone that has travelled outside of Canada in the past 14 days?

Yes ™                                       No ™   

4. Have you had close contact in the past 14 days with anyone with a new cough, fever or difficulty breathing or a confirmed case of COVID-19?

Yes ™                                       No ™   

 

If an individual answers “Yes” to any of these questions, they are not permitted to participate in any club activities.