OHF Health Screening Questionnaire (Innisfil Minor Hockey)

Print OHF Health Screening Questionnaire
This questionnaire must be completed by each individual prior to participation in each on-ice or off-ice activity. This questionnaire may be completed verbally. Are you currently experiencing any of these issues? Call 911 if you are. 1. Severe difficulty breathing (struggling for each breath, can only speak in single words) 2. Severe chest pain (constant tightness or crushing sensation) 3. Feeling confused or unsure of where you are 4. Losing consciousness If you are in any of the following at risk groups, we ask that you speak with your physician prior to participating. 1. 70 years old or older 2. Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors) 3. Having a condition that compromises (weakens) your immune system (for example, diabetes, emphysema, asthma, heart condition) 4. Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)
Questions
Are you currently experiencing any of these symptoms?
  1. Check All That Apply
  2. Check All That Apply
  3. Check All That Apply
  4. Check All That Apply
  5. Check All That Apply
  6. Check All That Apply
  7. Check All That Apply
  8. Check All That Apply
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  10. Check All That Apply
  11. Check All That Apply
  12. Check All That Apply
  13. Check All That Apply
  14. Check All That Apply
  15. Check All That Apply
  16. Check All That Apply
Physical Contact
For the remaining questions, close physical contact means: Being less than 2 metres away in the same room, workspace, or area for over 15 minutes. Living in the same home.
  1. Check All That Apply
  2. Check All That Apply
  3. Check All That Apply
Information
  1. Example: ###-###-####
  1.  Acknowledgement
Human Validation
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Printed from innisfilminorhockey.ca on Friday, September 25, 2020 at 11:18 AM